technology at your fingertips · 2020. 3. 28. · scott cravens, emt 800/547-7377 x1759...

Visit us online at EMSWorld.com JUNE 2016 | VOL. 45, NO. 6 $7.00

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Harnessing the Power of Data p. 29

21st Century Problem Solving p. 34

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EDITORIAL ADVISORY BOARDPeter Antevy, MDCEO & Founder, Pediatric Emergency Standards

James J. Augustine, MD, FACEPMedical Advisor, Washington Township Fire Department, Dayton, OH; Clinical Associate Professor, Department of Emergency Medicine, Wright State University, Dayton, OH; Director of Clinical Operations, US Acute Care Solutions

Raphael M. Barishansky, MPH, MS, CPMDirector, Office of Emergency Medical Services, Conn. Dept. of Public Health

Eric Beck, DO, NREMT-PAssociate Chief Medical Officer, American Medical Response

Bernard Beckerman, MD, FACEPAssociate Professor, School of Health and Behavioral Sciences, York College (CUNY), Jamaica, NY

Tom Bouthillet, NREMT-PCaptain, Town of Hilton Head Island (SC) Fire & Rescue Division

Kenneth Bouvier, NREMT-PDeputy Chief of Operations, New Orleans EMS; NAEMT President 2004–2006

Elliot Carhart, EdD, RRT, NRPAssociate Professor, Emergency Services Program, Jefferson College of Health Sciences, Roanoke, VA

Chris Cebollero, NREMT-PSenior Partner, Cebollero & Associates, St Louis, MO

Will Chapleau, EMT-P, RN, TNSDirector of Performance Improvement, American College of Surgeons

Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMTClinical Education Coordinator, VitaLink/AirLink, Wilmington, NC; Lead Instructor, Wilderness Medical Associates

Michael W. Dailey, MDAssistant Professor, Dept. of Emergency Medicine, Albany Medical College, NY

Thom DickEMS Educator, Brighton, CO

William E. Gandy, JD, LPEMS Educator and Consultant, Tucson, AZ

Erik S. Gaull, NREMT-P, CEM, CPPMaster Firefighter/Paramedic, Cabin John Park (MD) Volunteer Fire Department

Troy M. Hagen, MBA, NREMT-PCEO, Care Ambulance, Orange, CA

Martin Hellman, MD, FAAP, FACEPAttending Physician, Children’s Hospital of Pittsburgh, Pittsburgh, PA

Tim Hillier, Advanced Care ParamedicDirector of Professional Development, M.D. Ambulance, Saskatoon, SK Canada

Lou Jordan PIO, Fire Police Officer, Union Bridge (MD) Fire Department

C.T. “Chuck” Kearns, MBA, EMT-PEMS Consultant

G. Christopher Kelly, JDAttorney at Law, Atlanta, GA; Chief Legal Officer, EMS Consultants, Ltd.

Skip Kirkwood, MS, JD, EMT-P, EFO, CMO Director, Durham County (NC) EMS

Sean M. Kivlehan, MD, MPH, NREMT-P International Emergency Medicine Fellow, Brigham & Women’s Hospital, Harvard Medical School

William S. Krost, MBA, NREMT-PAdjunct Assistant Professor of Emergency Medicine, The George Washington University

Ken Lavelle, MD, FACEP, NREMT-P Clinical Instructor and Attending Physician, Thomas Jefferson University Hospital, Philadelphia, PA

Rob Lawrence, MCMIChief Operating Officer, Richmond (VA)Ambulance Authority

Todd J. LeDuc, MS, CFO, CEMAssistant Fire Chief, Broward Sheriff Fire Rescue, Ft. Lauderdale, FL

Mark D. Levine, MD, FACEPAssistant Professor, Dept. of Emergency Medicine, Washington University School of Medicine; Medical Director, St. Louis (MO) Fire Dept.

Tracey Loscar, NRP, FP-CBattalion Chief, Matanuska-Susitna (Mat-Su) Borough EMS, Wasilla, AK

Craig Manifold, DOEMS Medical Director, San Antonio Fire Department and San Antonio AirLIFE; Assistant Professor, University of Texas Health Science Center at San Antonio

Paul M. Maniscalco, MPA, EMT-PSenior Research Scientist & Principal Investigator, The George Washington University Office of Homeland Security

David Page, MS, NRPDirector, Prehospital Care Research Forum at UCLA; Paramedic, Allina Health EMS; Senior Lecturer, PhD candidate, Monash University

Richard W. Patrick, MS, CFO, EMT-P, FFDirector, Medical First Responder Coordination, Office of Health Affairs–Medical Readiness, U.S. DHS

Tim Perkins, BS, EMT-PEMS Systems Planner, Virginia Office of EMS, Virginia DOH, Glen Allen, VA

Michael E. Poynter, EMT-PExecutive Director, Kentucky Board of Emergency Medical Services

Vincent D. RobbinsPresident & CEO, MONOC, Monmouth-Ocean Hospital Service Corporation, Neptune, NJ

Mike RubinParamedic, Nashville, TN

Angelo Salvucci Jr., MD, FACEPMedical Director, Santa Barbara County & Ventura County EMS, CA

Scott R. Snyder, BS, NREMT-PFaculty, Public Safety Training Center, Emergency Care Program, Santa Rosa Jr. College, CA

Matthew R. Streger, Esq., MPA, NRP Partner, Keavney & Streger, Princeton, NJ; Senior Consultant, Fitch and Associates, LLC, New Brunswick, NJ

Dan Swayze, DrPH, MBA, MEMS Vice President/COO, Center for Emergency Medicine of Western Pennsylvania, Inc.

Cindy Tait, MICP, RN, PHN, MPHPresident, Center for Healthcare Education, Inc., Riverside, CA

John Todaro, BA, NRP, RN, TNS, NCEEEMS/CME Academic Department Coordinator, St. Petersburg College, St. Petersburg, FL

William F. Toon, EdD, NREMT-P EMS Training Manager, Loudoun County (VA) Fire, Rescue and Emergency Management; Battalion Chief - Training (ret.), Johnson County (KS) EMS: MED-ACT

David Wampler, PhD, LPAssistant Professor, Emergency Health Sciences, University of Texas Health Science Center, San Antonio, TX

Paul A. Werfel, MS, NREMT-PDirector, Paramedic Program, Clinical Asst. Professor of Health Science, School of Health Technology & Management, Asst. Professor of Clinical Emergency Medicine, Dept. of Emergency Medicine, Health Science Center, Stony Brook University, NY

Katherine West, BSN, MSEd, CICInfection-Control Consultant, Infection Control/Emerging Concepts, VA

Gerald C. Wydro, MD, FAAEMChief, Division of EMS, Temple University School of Medicine, Philadelphia, PA

Matt Zavadsky, MS-HSA, EMTDirector of Public Affairs, MedStar Mobile Healthcare, Ft. Worth, TX

Published by SouthComm Business Media, Inc PO Box 803 • 1233 Janesville AveFort Atkinson WI 53538920-563-6388 • 800-547-7377Vol. 45, No. 6PUBLISHERScott Cravens, EMT800/547-7377 x1759 [email protected]

EDITORIAL DIRECTORNancy Perry800/547-7377 x1110 [email protected]

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EMS World magazine® (USPS 947-780; ISSN 2158-7833 (print); ISSN 2159-3078 (online)) is published monthly by SouthComm Business Media, LLC. Periodicals postage paid at Fort Atkinson, WI 53538 and additional mailing offices. POSTMASTER: Send address changes to EMS World, PO Box 3257, Northbrook, IL 60065-3257. Canada Post PM40612608. Return undeliverable Canadian addresses to: EMS World, PO Box 25542, London, ON N6C 6B2.

Subscriptions: Individual subscriptions are available without charge in the U.S. to qualified subscribers. Publisher reserves the right to reject non-qualified subscriptions. Subscription prices: U.S. $52 per year, $98 two year; Canada/Mexico $72 per year, $139 two year; All other countries $103 per year, $196 two year. Student rate $19 per year. All subscriptions payable in U.S. funds, drawn on U.S. bank. Canadian GST#842773848. Back issue $10 prepaid, if available. Printed in the USA. Copyright 2016 SouthComm Business Media, LLC.

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For More Information Circle 12 on Reader Service Card

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FEATURES

39 A Difficult Intubation: Ankylosing SpondylitisPlanning ahead is key to mastering the difficult airwayBy William E. “Gene” Gandy, JD, LP, Steven “Kelly” Grayson, NREMT-P, CCEMT-P, & Jason Kodat, MD, EMT-P

44 7 Alternative EMS Careers: Part 2 If you’re tired of the 9-1-1 grind, opportunities abound for delivering nontraditional EMSBy Mike Rubin

An EMS Guide to Depression and Bipolar Disorder Providers need a thorough understanding of mood disorders to provide effective careBy Robert J. Sullivan, BA, NREMT-P, & Shauna Sullivan, LCSW, LLC39

48

LETTERS TO THE EDITOR: Letters may be edited for clarity or space. E-mail [email protected].

SUBMISSIONS: E-mail queries, manuscripts, press releases and news items to [email protected].

PERMISSIONS: E-mail requests to [email protected].

CONTAC T USfacebook.com/emsworldfans twitter.com/emsworldnews

linkedin.com/groups/1853412 youtube.com/EMSWorld

JUNE 2016 Vol. 45, No. 6

COVER REPORT: TECHNOLOGY AT YOUR FINGERTIPS

COLUMNS

47 LUDWIG ON LEADERSHIPWhat EMS Leaders Can Learn From Admiral RickoverBy Gary Ludwig, MS, EMT-P

58 THE MIDLIFE MEDICYour Mileage May VaryBy Tracey Loscar, NRP, FP-C

DEPARTMENTS 8 EMS World Online

10 From the Publisher

12 News Network

57 Ad Index

57 Classified Ads

16 The Future of Motor Vehicle Cra sh ResponseHow AACN technology can accurately predict injury severity and better manage resources on sceneBy Susanna J. Smith

21 Disruptive Technologies in EMSInnovations will transform both operations and careBy Susanna J. Smith

29 Harnessing Data for Real ImprovementsThree projects demonstrate how to use data to improve patient care in EMS systemsBy John Erich

34 21st Centur y Problem SolvingEvolving technologies are changing the way we communicateBy EMS World Staff

WEBCASTS

twitter.com/emsworldnews www.linkedin.com/groups/1853412facebook.com/emsworldfans

How to Plan for, Prepare and Deliver High-Value EMS SimulationScheduled for June 15, 11:30 a.m. ETPreparing EMS providers for practice is complicated. Shrinking access to clinical sites, opportunity to practice high-stakes interventions and teamwork skills are just a few challenges where simulation is positively impactful. In this webinar, join John Todaro, president of the National Association of EMS Educators and one of the nation’s authorities on simulation education, for tips on planning, facilitating and evaluating simulated patient engagements. Emphasis will be placed on identifying critical gaps in fulfilling curriculum goals, aligning simulation objectives to national standards and developing learners’ competence, all while operating in a low-resource environment.Sponsored by

FEATURES

Stuck in Reverse >> EMSWorld.com/12205052What if EMS were all volunteer? Mike Rubin highlights advantages of such an outcome in June’s Life Support.

Moulage of the Month >> EMSWorld.com/12205020Bobbie Merica continues her guide to simulating injuries and illnesses through effective use of moulage. This month: industrial injury, snakebite.

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Crisis ManagementRethinking our response to the mentally ill

With Memorial Day just passed, it seems appro-

priate to shine a spotlight on a department

that has gone out of its way to help our

veterans.

In January 2012, a 25-year-old former recon Marine

sergeant, who had served two tours in Iraq, was shot

dead after what was seemingly an unprovoked evening

of pool playing (for details of the incident see http://

bit.ly/1NphBgU). That event struck a chord at the Phoenix Fire

Department, where medical director Dr. John Gallagher (pic-

tured) recognized many of the agency’s psych patient calls were

for veterans. They, like any psych patients, are taken to the ED

and admitted for three or more days of observation well after the

episode that landed them there in the first place. Not anymore.

Phoenix’s Crisis Response Network (CRN) program (crisis

network.org) provides care of the seriously mentally ill. The PFD

has partnered with the CRN so that when a call comes in that

is psychiatric in nature without a medical problem, the

PFD calls in CRN’s two-person counseling unit, which

works with the patient. “Previously we would take the

patient to the ED, now we call this unit,” Gallagher told

me when I visited PFD earlier this year. “They transport

them to the urgent psychiatry center or just send them

to outpatient treatment.”

And there’s an added benefit, Gallagher says: “We

didn’t get into the project with the idea of making money, but

the AHCCCS (Arizona Health Care Cost Containment System)

insurers said, ‘We think we can cover this.’ in the near future,

Medicaid/AHCCCS will pay PFD $150–$250 for a non-transport,

saving the healthcare system over $4,000 by avoiding an ambu-

lance transport plus hospital stay.” The hope is to keep adding

more districts to the project until it is statewide. For more on the

AHCCCS program, see http://1.usa.gov/1ZAPH2f. For more on my

visit to PFD, see EMSWorld.com/12206438.

Dallas MIH-CP Program Reduces Enrolled Patients’ Calls by 82%

Since Dallas Fire-Rescue began a proac-

tive pilot program in March 2014 involv-

ing firefighter-paramedics making house

calls, the frequency of 9-1-1 calls by

patients in its Mobile Community Healthcare

Program has plummeted by 82%.

The drastic reduction has saved the city sig-

nificant sums via fewer emergency runs, and

hospitals by fewer emergency room visits for

patients, many uninsured. The eighth-largest

city in the United States, Dallas covers some

380 square miles and 1.18 million residents.

“We’ve seen a run reduction among those

enrolled in this program from 2,870 calls in the

year before enrollment to 510. That’s monu-

mental,” says Norman Seals, assistant chief

of the Emergency Medical Services Bureau for

the Dallas Fire-Rescue Department.

The Mobile Community Healthcare Program employs Dallas Fire-

Rescue community paramedics to focus on chronically ill patients

and those recently discharged from a local hospital. Paramedics

evaluate medical needs, teach enrolled patients ways to better

manage their health and provide them with referrals to neces-

sary services.

“In the ‘proof of concept’ phase in the first few months of the

program, we looked at what was being done in other places with

similar programs and designed our own in a fire department-based

system,” says Marshal Isaacs, MD, medical director of Dallas Fire-

Rescue. “Was it safe? Was it beneficial to patients? Was it good for

the healthcare system? We proved that it was. And it has been.”

For example, a hospital partner may refer a discharged trauma

patient to Dallas Fire-Rescue. Paramedics go into the field to ensure

the patient is properly set up for home recovery and is taking medi-

cations as prescribed. The hospital partner pays Dallas Fire-Rescue

for their services, which costs less than readmission penalties.

Lessons Learned“Case management has been a challenge,” says Seals. “As fire-

fighters, our case management process generally lasts anywhere

from 30 minutes to four hours. In this program, we’re dealing with

patients for sometimes 6–8 months before they ‘graduate.’ Dr.

Isaacs has been great about bringing hospital case management

principles together with ours.”

Over the course of the pilot program’s first two years, Isaacs has

been surprised by “how little medical intervention these patients

need acutely, especially high-frequency patients.”

What they found instead was that that the vast majority of work

the community paramedics are doing with patients falls under the

auspices of education; medication reconciliation, inventory and

management; and healthcare system navigation.

“Hospital patients often have little to no social support,” explains

Seals. “Perhaps they lack transportation. Sometimes they lack

food. We’ve been able to form really good relationships with 50

or 60 community-based partners that cover those services. That’s

been absolutely critical to the success of the program.”

Since the program’s onset, only 22 of 297 referred patients, or

7.4%, have refused service. “We’re not sure if it’s a privacy issue,

for good or bad reasons, but we know the subset of patients we

can only take so far in the program, if at all,” Isaacs says. “Those

patients tend to have severe mental illness or recalcitrant alco-

hol and substance abuse disorders and are unwilling to accept

treatment.”

What’s Next?The pilot program has grown from four to seven paramedics. Hos-

pital partners have grown from one—Parkland Health & Hospital—

to three health systems for contracts totaling $700,000.

“For the most part, the program is still city-funded,” says Seals,

adding that Dallas Fire-Rescue was the first metropolitan fire-

based EMS agency in the United States to develop a program of

its kind. “The end goal is to be at least budget-neutral for the city,

which we plan to do with more hospital partners and through

grants.”

A custom data management system is being developed that,

when fully implemented, will propel the Mobile Community Health-

care Program.

“There are so many areas of need,” says Seals, adding that hos-

pice and mental health patients would benefit from the program to

reduce revocation. “We aren’t trying to replace existing programs

or services. Our role is to fill some gaps.”

—Pepper Jeter, Associate Editor

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U.S. Stroke Hospitalizations Drop Overall, But Increa se for Young People and African-AmericansNationwide, fewer people overall are being hospitalized for ischemic strokes,

which are caused by artery blockages, but among young people and African-

Americans, stroke hospitalizations are rising, according to new observational

research in the Journal of the American Heart Association, the open-access journal

of the American Heart Association/American Stroke Association.

Between 2000–2010, the number of adults admitted to U.S. hospitals with

ischemic stroke fell 18.4%, according to researchers who analyzed a national

database that collects information on about 8 million hospital stays each year.

Ischemic strokes are the most common type of stroke.

“Overall, the hospitalization rate is down, with the greatest drop in people

aged 65 and older. We can’t say from this study design what factors have led to

this decline, but it may be that preventive efforts, such as better blood pressure

and blood sugar control, are having the effect we want in this age group,” said

Lucas Ramirez, MD, neurology resident at the Keck School of Medicine at the

University of Southern California in Los Angeles.

However, while the hospitalization rates fell 28% in people aged 65–84 and

22.1% in those 85 and older, there was an increase in younger adults—up 43.8%

in people aged 25–44 and up 4.7% in those aged 45–64.

Age-adjusted hospitalizations for ischemic stroke declined in both whites

(down 12.4%) and Hispanics (down 21.7%) between 2000 and 2010, but they

increased 13.7% in African-Americans.

“African-Americans already had the highest rate of stroke hospitalizations,

and it has unfortunately increased. This reinforces that we need to make sure

our efforts for stroke prevention and education reach all groups,” Ramirez said.

As expected, based on previous studies the 2000 to 2010 data showed that

women have lower age-adjusted rates of stroke hospitalization and experienced

a steeper decline during the decade (down 22.1%) than men (down 17.8%).

—American Heart Association

The Richmond Ambulance Authority (RAA) received

an American Heart Association Mission: Lifeline Gold

Award last month.

Every year more than 250,000 people experience

a STEMI, or ST-elevation myocardial infarction, a

type of heart attack caused by a complete blockage

of blood flow to the heart that requires timely treat-

ment. EMTs and paramedics play a vital part in the

system of care for those experiencing heart attacks.

Since they often are the first medical point of con-

tact, precious minutes of lifesaving treatment time

can be saved by calling a STEMI alert and triggering

an early response from the participating STEMI cen-

ters. Mission: Lifeline strives to equip first responders

with resources and tools to help improve the quality

of care for patients and help build systems of care

in communities across the U.S.

“The Richmond Ambulance Authority has always

been dedicated to making our organization among

the best in the country. The American Heart Associa-

tion’s Mission: Lifeline program is improving STEMI

systems of care with the goal of improving the qual-

ity of care for all STEMI patients,” says Wayne Har-

bour, RAA chief clinical officer. “We are pleased to be

recognized for our dedication and achievements in

emergency medical care for STEMI patients.”

To qualify for a Mission: Lifeline Gold Award, RAA

had to ensure it achieved a number of measures,

including ensuring that a minimum of 75% of its

STEMI patients arrived at hospital and received

definitive treatment such as a percutaneous coro-

nary intervention (PCI) within 90 minutes of the 9-1-1

call for service.

Virginia A gency Wins Mission: Lifeline Gold STEMI Award

The FirstNet E xperience: Ohio Video Game Vir tually Demonstrates Network’s PotentialThe OhioFirst.Net program has

developed a unique way for peo-

ple to experience the potential

of the FirstNet network—a video

game that allows users to virtu-

ally see the increased situational

awareness the nationwide pub-

lic safety broadband network

will provide to first responders.

The PC-based video game

applies a real-world scenario—a rescue during a structural fire—in two scenes.

In the first scene, the player uses current technology to complete the rescue. In

the second scene, the player completes the rescue with enhanced situational

awareness tools that will be made possible through FirstNet’s public safety

broadband.

The game takes pieces of traditional information, like maps and building blue-

prints, and adds them to the heads-up display of the video game.

For more, see EMSWorld.com/12207120.

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Results of a recent study suggest that advanced automatic crash notification (AACN) technol-ogy, which sends telemetry data in the event of a motor vehicle

accident, can be used to accurately predict the injury severity of vehicle occupants.

The research by Stewart Wang, MD, PhD, director of the Program for Injury Research and Education at the University of Michigan

and a trauma surgeon, analyzed data from 836 vehicles with OnStar AACN capabili-ties that were involved in crashes involving 924 occupants between January 2008 and August 2011.

Wang used an algorithm to analyze three types of data from each accident: crash fac-tors, vehicle factors and occupant factors. Results of the algorithm were then used to predict whether each vehicle occupant met

the 20% or higher risk of having an Injury Severity Score (ISS) of 15+, which is the threshold set by the National Expert Panel on Field Triage for urgent transport to a trauma center.

Accuracy of AACN DataThe Wang et al. study1 showed that when the gender and age of the vehicle occu-pants were known, the algorithm could use

By Susanna J. SmithHow AACN technology can accurately predict injury severity and better manage resources on scene

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AACN data to predict which occupants had a high likelihood of severe injury with a sensitivity of 64% and a specificity of 96%. Without information about age and gender, the sensitivity was 45% while the specific-ity was 98%.

“Sixty-three percent sensitivity may not sound like an impressive number but when you look at the experience over the last four to five decades, it is a significant improve-ment,” says Wang. “Even trained person-nel are no more than 40%–50% accurate in picking out patients with severe injuries.

“In the past, EMS did not usually receive AACN data or if they did, they were appro-priately skeptical because it was a prediction that wasn’t proven. But with this new trial, we know we should be taking AACN very seriously. If the vehicle is reporting that there is a high risk of severe injury, you should see that report as at least as accurate or more accurate than your best colleague.”

Data Collected by AACNA panel of experts on AACN technology and patient triage have made recommendations on what information a vehicle should trans-mit in the event of a crash, which include:

» Whether the crash included multiple impacts,

» The vehicle’s change in velocity, » The principle direction of force, » Whether or not seat belts were in use,

and » The type of vehicle.

Right now, when an AACN-enabled car is in an accident, the vehicle automatically routes essential telematics information to a vendor-operated call center. The call center then processes the information and calls

the nearest public safety answering point (PSAP).

“With next-gener-ation 9-1-1 technolo-gy, however, there is the potential for the data to flow directly to the PSAP,” says Crystal McDuffie, com-munications center and 9-1-1 services man-ager at APCO International. “The PSAP can then pass this information to the responders, although current call centers would remain

a vital link as the first contact.”But not all of vehicle telemetry

data needs to be relayed to first responders.

“EMS crews are busy taking care of things on the

scene. They don’t need to be inundated

with a bunch of complicated informa-

tion, what they need is a simple indication of whether a patient is at high risk of severe injury,” says Wang, which was his aim in developing the injury severity prediction algorithm.

Wang goes on to say that a trauma cen-ter, however, might need other information: “The medical team at the trauma center will be very interested in the details of the crash because this information can help us nar-row down the types of injuries we worry about the most.”

AACN Helping EMSTo help EMS, 9-1-1 and emergency medicine professionals learn more about AACN tech-nology and the implications of AACN crash data, a new, one-hour online training pro-

gram will be available this summer at www.aacnems.com. This course teaches EMS providers and medical directors about the biomechanics of crash injuries, the research that supports the validity of AACN predic-tions, how data can be used to predict injury severity and how to integrate this data into local EMS systems.

The online training program is supported by the American College of Emergency Phy-sicians (ACEP) and the National Association of EMS Physicians (NAEMSP), with funding from the National Highway Traffic Safety Administration (NHTSA).

Scott Sasser, MD, associate director for International Programs for the Center for Injury Control at Emory University and the principal investigator on the ACEP/NAEMSP training course says, “EMS pro-fessionals, medical directors and 9-1-1 cen-ter directors need to learn about this new technology that is out there and growing in prevalence. We need to know how the information supplied by the vehicle can not only help identify injury patterns but can also help with everything from resource allocation to destination decision-making.”

Sasser, who is also an emergency room physician, points out that AACN data offers EMS and 9-1-1 personnel three main advan-tages when responding to a crash. AACN provides faster notification of the crash, the exact location information for the crash, and telemetry data, which can be used to predict injury severity and even injury pat-

A ACN Course Over viewTo help EMS, 9-1-1 and other medical professionals learn more about AACN technology and the implications of AACN crash data, a new one-hour online training program will be available this summer at www.aacnems.com. This course offers medical directors, EMS personnel and 9-1-1 directors an introduc-tion to vehicle telemetry crash data and an understanding of what happens in a crash. The course reviews the science behind the AACN injury severity predic-tive algorithms, how AACN fits into the CDC’s Field Trauma Triage Guidelines and how this technology is being implemented in local systems.


terns based on the engineering of the car and the mechanics of the crash.

“We will always need the expertise of the professionals in the field to interpret the data, get people out of the vehicles, safely assess them, and transport and treat them en route,” says Sasser. “But the data we can get from AACN adds important informa-tion to the data points we can get in field. This data can help us allocate the appropri-ate resources to the scene.”

Cory Richter, battalion chief at Indian River County Fire and Rescue in Vero Beach, FL, is a big proponent of the technology and thinks that its use and accuracy will only improve in the future.

“The amazing thing about this infor-mation is you can use it before you even get to the scene. You might not have even left the station and it can help change your response,” Richter says. “Where it specifi-cally changes the EMS response is when we prelaunch the helicopter or call in additional

units before we get on scene because we already know we need them.

“Sometimes it’s going to tell us it’s a trauma alert and it’s obvious because the patient is unconscious or unresponsive. But where it can really make a difference is if they [the patients] are up walking around or awake and alert but have potential internal injuries because of the mechanism of injury. In those cases, I tell my crews to do a really thorough evaluation and err on the side of transporting them to a trauma center.”

Future Directions of AACN TechnologyBeyond the potential for AACN to direct a faster, more informed EMS response, this technology also has the potential to change trauma care, save more lives and help manu-facturers build safer vehicles.

“The next step we want to look at is whether AACN can help us lower morbidity and mortality with motor vehicle crashes,” says Sasser.

Wang is particularly interested in how AACN can help with triage and diagnosis in the trauma center. “At a trauma center, we want to know things like if it was a driver involved in a left-sided crash. In that case, there might be high likelihood of a pneu-mothorax injury or a spleen injury because the spleen is on the left side. Knowing more about a crash can help us narrow down the possible diagnoses, which makes me a far better doctor.”

Wang, who does a lot of crash research, says, “Right now, we spend a lot of time going and looking at the car, trying to examine what is the principle direction of force, direction of the crash, and how severe it was. The sen-sors in the vehicles are far more precise. With time and enough data, we will definitely be able to use this information make cars safer.”

Widespread Adoption of AACNAlthough AACN technology is not yet wide-spread in the U.S. automotive fleet, Sasser cautioned it is important for EMS, 9-1-1 and emergency medicine professionals to get ahead of this trend and understand the technology.

“The use of this technology in cars is going to be increasingly prevalent,” says Sasser. “As a profession, I would hate to

see us get caught five or 10 years down the line and not be adequately prepared for it by developing the education, policies and protocols we need now. I think this technol-ogy will be well received by the EMS com-munity because of its potential impact on our patients. We’ve got to keep supporting it, talking about it, getting educated about it and looking at the research on it.”

“I think EMS leadership should really be paying attention to AACN because it’s cutting-edge technology,” says Richter. “The future of EMS, in terms of motor vehicle crashes, is going to be notifications and information coming in from vehicles, sight unseen. We need to embrace this technol-

ogy and use it now so the next generation of EMTs and paramedics are comfortable with it and can use it more as it gets more prevalent.”

SummaryNew research is showing that advanced automatic crash notification systems can be used to accurately predict the injury sever-ity of vehicle occupants in motor vehicle crashes. These early notifications can help EMS crews know likely injury severity and the number of injured occupants before they get on scene and direct a more informed EMS response.

RE FE RE N CE

1. SC Wang, CJ Kohoyda-Inglis, JB MacWilliams, et al. Results of First Field Test of Telemetry Based Injury Severity Prediction. www.acep.org/globalassets/support/innovatED_supportfiles/RESULTS-OF-FIRST-FIELD-TEST-OF-ELEMETRY-BASED-INJURY-SEVERITY-PREDICTIO.pdf.

AB O U T THE AU TH O R Susanna J. Smith is a content strategist and

freelance writer who focuses on the future of healthcare and how new technologies and care models are reshaping the healthcare industry. She holds a master’s in public health from Columbia University and has worked as a writer, editor and researcher for more than 10 years. Follow her work at

@SusannaJSmith and susannajsmith.com.

This technology also has the potential to change trauma care and help manufacturers build safer vehicles.

A ACN Project Stakeholders

The Advanced Automatic Collision Notification project is a partnership between the American College of Emergency Physicians and the National Association of EMS Physicians and is funded by the National Highway Traffic Safety Administration.

Other stakeholders in the project are: American Academy of Pediatrics, American College of Surgeons/Committee on Trauma, Association of Public Safety Communications Officials, International Association of Fire Chiefs, National Academy of Emergency Medical Dispatch, National Association of EMS Educators, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Emergency Number Association, AACN vendor and automakers, including Onstar, Ford, SiriusXM and other major automakers, listed at aacnems.com.

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EMSWORLD.com | JUNE 2016 21

By Susanna J. Smith New technologies, including advances in

remote monitoring systems, offer the promise of transforming the delivery of EMS, impacting everything from dispatch to treatment and diagnosis in

the prehospital setting and moving EMS toward a more predictive, rather than reactive, response model.

Next month, at the Pinnacle EMS Leadership Forum (pinnacle-ems.com) in San Antonio, TX, Scott

Somers, PhD, a professor of public safety practice at Arizona State University and a former member of the National EMS Advisory Committee, and Guillermo Fuentes, MBA, a partner with Fitch & Associates, will speak about the potential of both new and existing technologies to radically disrupt EMS as we know it today. In advance of the conference, I spoke with Somers and Fuentes about how they think technology will overhaul EMS.

Disruptive Technologies in EMSInnovations will transform both operations and patient care

Social Media Intelligence to Drive EMS PreparednessSocial media listening technologies offer EMS and other public safety agencies

the ability to analyze and interpret public social media conversations in real time,

linked to specific geographical areas.

Somers points out that real-time analysis of information such as Facebook

posts, tweets and Google searches has been used to track the spread of flu

across the U.S., for example. Teams at John Hopkins University and Purdue

University have developed algorithms for using social listening to visualize and

predict the spread of flu.1, 2

Accurate predictions of the spread of flu or other infectious diseases could

help direct the efficient deployment of EMS and healthcare resources—includ-

ing public education, flu shots, flu treatment and medical personnel—to areas

most at risk of severe outbreaks.

“Social listening technologies can zoom in on the pulse of what is taking place

in a community,” says Somers. “They can become a resource for citizen engage-

ment or public health and public disaster management.”

Wearables and Home Monitoring Wearable mobile devices such as

the Fitbit, Apple Watch, Google

Glass and the Under Armour Band

have gained widespread traction

in the consumer marketplace. Some

estimates suggest that as many as 1 in 5 American

adults owns a wearable device.3

“We are now beginning to see how embedded

sensors and wearable devices can be used by physi-

cians or EMS agencies,” says Somers.

Somers points to cardiac patients as a great

example where continuous monitoring via wear-

ables could be valuable and might generate con-

tinuous data streams to cardiologists, who can then

monitor patients in real time.

A recent example of this is an emergency room

doctor in New Jersey who used heart-rate informa-

tion from a patient’s Fitbit to pinpoint the exact time

when atrial fibrillation started, which informed treat-

ment choices.4

Somers envisions EMS responding to notifications

from wearables and home monitors and serving as

a link between the patient and physician in an inte-

grated healthcare system.

New types of wearables, not yet on the market,

are expected soon. For example, AliveCor is devel-

oping a medical-grade EKG band for the Apple

Watch,5 and a team at the University of California

at San Diego is working on a temporary tattoo that

can easily monitor blood glucose levels.6

EMSWorld is a media sponsor for the Pinnacle 2016 EMS Leadership Forum, to be held July 18–22 in San Antonio, TX. See pinnacle-ems.com.

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Shift from Treatment to Prevention to PredictionThe continuous data streams from social

media platforms, internet searches, home

monitoring devices and wearables all gen-

erate large pools of data ripe for analysis,

which is one of the next big directions for

disruptive technologies.

Somers points out that big data ana-

lytics tools could help EMS move from a

reactive, treatment-focused response to

a preventive response driven by predictive analytics prior to an

incident happening. Somers highlights the work of the New York

City fire service in predictive analytics to illustrate his point.

“New York City has a great program on smart firefighting called

Firecast,” says Somers. “This program takes in and processes data

about buildings that New York has found to be highly related to

outbreaks of fire.”7

The program doesn’t just look at traditional data used to pre-

dict fires but also collects data from different city departments,

including complaints about trash or rodents, crime rates and the

existence of nearby abandoned structures, as well as data from

sensors on buildings, to predict each building’s likelihood of a fire.

This predictive data analysis is then used to rank buildings and

schedule fire inspections for those deemed to be at high risk.

The predictive analytics approach could be applied in EMS and

public health by using statistical models to predict communities

with a high likelihood of accidents, infectious disease, cardiac

arrests or drug overdoses. Somers points out that with predictive

analytics in place, EMS can then shift its resources from being

focused on responsive actions towards aggressive prevention

efforts targeted at high-need areas.

Better tools for big data analytics could also help EMS provid-

ers process new, big data streams and inform immediate care

decisions. For example, in the field of oncology the IBM Watson

computer is already being used to help inform cancer treatment

decisions.8

While not currently an application of supercomputers, fast

supercomputing data analysis could be used in the future to ana-

lyze crash data, for example, as advanced automatic crash noti-

fication technology becomes more widespread in cars.

Much like IBM Watson is being trained to interpret more and

more oncology information, supercomputers could be fed more

data about car crashes, including type of vehicle; type of crash;

speed; and the size, age and position of occupants. They could

use this information along with outcomes data to refine their

predictions over time and aid in an increasingly informed medical

response.

Augmented Reality Augmented reality or augmented user

experience technologies, which offer users

a real-world view supplemented by addi-

tional information such as sound,

video overlays, relevant data,

GPS and other directional

information, are another area

that may bring big changes to

EMS, particularly in the train-

ing of new EMS professionals.

Somers points out that the

heightened situational awareness

offered by augmented user experience

technologies, such as advanced geographi-

cal locating technology and night vision, is

currently used in battlefield settings.

Somers suggests that for EMS the most

immediate application will be in training;

for example, augmented reality tools can

help students learn how to auscultate a

patient by overlaying images of the loca-

tion of the vital organs onto a body in front

of them. These applications could also find

appropriate uses in disaster response.

Technology to Overhaul EMS OperationsNew technologies are likely to also radically alter EMS operations and

dispatch. Fuentes argues that EMS teams that are not jumping to use

hosted technologies but are instead sticking with expensive, stand-

alone communications centers will find themselves being “the dino-

saurs of EMS communications.”

“Within the next decade, I think you are going to see communications

centers that are fully hosted, which means they could close at 8 p.m.

and transfer all their calls to a statewide [communications] center,” says

Fuentes. “You could have dispatchers literally working from home, if they

wanted to, because there is nothing to stop them from doing it.”

With voice over IP (internet protocol) technologies it becomes easy and

affordable to transmit calls anywhere in the world and from any tower to any vehicle

or person. Fuentes sees the field moving in the direction of subscription-based, hosted

technology solutions rather than agencies fully funding a communications center.

Hosted solutions also bring down the cost of back-up communication systems and

create redundancies by allowing for the call load and information to easily be spread

and transferred among centers. Fuentes predicts that once the cost of communications

technology falls, smaller EMS companies will again gain competitive leverage in a market

where they are quickly losing a foothold now.

Fuentes looks to the example of Square, a mobile payments company, which made

it possible for many independent and small businesses to set up affordable, mobile-

based credit card payment processing systems and stay in business. He envisions a similar

affordable small business solution for call operations to help small ambulance companies

compete in the EMS industry.


Outside Technologies: Security & Driverless CarsBoth Somers and Fuentes suggest that

some of the most disruptive technolo-

gies will be those developed outside

of the EMS industry. Front of mind for

Somers are cybersecurity technologies,

which are becoming a more pressing

need with recent hacks on hospital sys-

tems such as Washington, DC’s Medstar

Health and Los Angeles’s Hollywood

Presbyterian Medical Center.9, 10

“Cybersecurity is going to be a huge technology challenge for

EMS agencies in the future,” says Somers. “Consumer confidence

is important. If we see massive data breaches in sensitive health-

care information, it will quickly erode consumer confidence and

put up roadblocks to the types of digital advances that could

improve healthcare.”

Autonomous driving vehicles are another example of a

technological advance that could significantly impact the

EMS industry by changing both deployment models and

call demand. “Think about an autonomous fire truck,” says

Somers. “Will we have to have people at the fire station 24

hours a day if the fire truck can drive itself to the incident?”

Somers points out that this simple change in a deployment

strategy could free up human resources for other tasks like mobile

integrated health work or fire inspections.

Fuentes, too, sees autonomous vehicles as a huge opportunity in

the future to shift the demand on and use of EMS resources. Motor

vehicle accidents represent about 15% of calls for EMS, fire and

police. If autonomous vehicles deliver on the promise to signifi-

cantly reduce the number and severity of motor vehicle accidents,

it will significantly cut down on EMS calls.

“The future is going to be so externally driven and we need to

become more educated on what is going to be coming so that

we are nimble enough to react,” says Fuentes. “In this case, if car

accidents go down significantly, we have to ask ourselves,

what are we going to do with that? Are we going to

adjust our staffing levels? Are you going to real-

locate those resources elsewhere? Are you going

to stop buying the heavy apparatus and equip-

ment to cut people out of cars because you

won’t need them much anymore?”

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Conclusion When it comes to the future of technology and EMS systems, the first step is for the EMS pro-fession to fully embrace the reality that change is coming.

“We have to accept that many of the things we have been doing in EMS for years are not going to be what carries this industry into the future,” says Fuentes.

Leaders in EMS can look to the broader healthcare community for examples of how new technologies like nanoengineering, big data supercomputing, vehicle telemetry and healthcare wearables could drive big changes in healthcare that in turn influence the delivery of prehospital care.

References available online at EMSWorld.com/12206669.

AB O U T THE AU TH O R Susanna J. Smith is a content strategist and

freelance writer who focuses on the future of healthcare and how new technologies and care models are reshaping the healthcare industry. She holds a master’s in public health from Columbia University and has worked as a writer, editor and researcher for more than 10 years. Follow her work at @SusannaJSmith and susannajsmith.com.

Beaming the Doctor to the PatientSome industry leaders like Fuentes envision a system in which tele-

medicine allows doctors to communicate with and evaluate

patients in their homes, leading to a physician-centric model

where EMS practitioners play an important role, but have less

autonomy.

“I envision a dispatch center where all the low-acuity calls are

evaluated by a physician in a call center,” says Fuentes.

Others see the potential of telemedicine-based, physician-

managed collaborations between EMTs, paramedics and other

providers that extend the scope of care offered in a prehospital set-

ting, including emergency care for acute problems like strokes. The Cleveland Clinic

and the University of Texas Health Science Center at Houston have both piloted and

reported successes in reducing time to treatment for stroke patients when using a

mobile stroke care team made up of a paramedic, an EMT, a registered nurse and a

CT tech supported via video conference by a hospital-based vascular neurologist.11

Glenn Leland, with Priority Ambulance in Knoxville, TN, has spoken about the poten-

tial for EMS-based telemedicine teams to power virtual hospitals in patients’ homes12

by setting up “hospital beds” there and connecting patients for home-based monitor-

ing and follow-up.

In 2014, the Icahn School of Medicine piloted a program offering mobile acute care in

patients’ homes using paramedics supported by physicians through video conferenc-

ing and messaging apps.13 While the program has not yet worked out a sustainable

reimbursement model, it has reported a significantly lower cost of care, higher patient

satisfaction, and some decrease in hospital readmissions and mortality.


A lot of smart people do a lot of innovative things to advance healthcare and technology these days. Too often their contributions remain unrec-

ognized or underappreciated.That’s why ImageTrend, a Minnesota-

based developer of EMS data management and related software, created its Hooley Awards. First given in 2015, the honors

recognize noteworthy users of ImageTrend products in three categories:

» Innovation Awards, for use of products to meet the needs of a service, department, hospital or state in a new or innovative way;

» Service Awards, for using data to improve community safety; and

» New Frontier Awards, for services, departments, hospitals or states that break new ground.

EMS World helped judge last year’s awards, which were respectively won by the Missouri Time Critical Diagnosis Team; Emory University EMS; and the East Baton Rouge (LA) EMS Community Integrated Health Program. All the finalists submitted worthy efforts, and for this year’s technology issue, we profile three additional outstanding ones.

Put the Data In, Get the Data OutThe problem: When value-based reimbursement finally comes to EMS, we’ll need to be ready to demonstrate the good job we do. How? By developing quality metrics that define good patient care and then meeting and exceeding them.

Lots of people have developed key performance indicators for EMS, including NHTSA/NASEMSO in 2009, the Metropolitan Medical Directors in 2007, and professional associations in areas like trauma, cardiac and stroke. Today’s EMS Compass Initiative is a federally funded effort to develop performance measures that can help systems gauge and improve the quality of their care.

In Washington they had a similar idea a while ago. The work leaders there have done to develop KPIs and facilitate reporting and benchmarking will put their state’s services ahead of the game once their transition to version 3 of NEMSIS is complete.

The solution: The Washington State Prehospital Technical Advisory Committee began work on EMS KPIs as part of a three-year strategic plan in 2011. Work groups toiled for three years before the state’s EMS and Trauma Steering Committee okayed them for use in 2014.

“The importance of having the clinical measures is really why we did it,” says Melissa Belgau, administrator for the Washington EMS Information System (WEMSIS). “We think EMS will be wanting to do pay-for-performance types of things, and we’ll need proof we’re providing quality care. The idea is that we’re going to decide what to measure before someone tells us what to measure.”

The 27 KPIs that emerged meet EMS Compass performance measure criteria, are supported by substantial evidence in medical literature and can be measured and reported from WEMSIS data. A range of stakeholders from across the state helped craft them,

in particular medical program directors (MPDs), physicians for each county who oversee the clinical performance of EMS per-sonnel. WEMSIS would be the primary source for data collection and analysis.

The KPIs were drafted relatively broadly and can be adopted in part or whole or modified for local use. The resulting reports can be configured by local queries so agencies can compare their own data to others similar or nearby. What they’ll ensure, however, is that services measure the same things the same way, allowing effective benchmarking.

State leaders enlisted ImageTrend to add that benchmarking functionality to its Report Writer program, which helps adminis-trators gauge KPIs and track QA/QI elements.

How it was implemented: Well, about that: Because not all systems in Washington are compliant with NEMSIS v3, it hasn’t been—yet. That is, the KPIs are available for use, and some jurisdic-tions have embraced them, but the full reporting/benchmarking capability is still waiting to be tapped.

“If you’re the only agency in your county using the new system, there’s nothing to benchmark against,” notes Belgau. “So while the KPIs won’t been used on a state level until NEMSIS v3, counties and some EMS agencies have been using them at a local level with their v2 data.”

Agencies face a January 2017 deadline to upgrade to v3. But the state may experiment with some early reporting later this year; its biggest ePCR vendor converts to v3 in September and can start populating data then. “Those initial reports,” Belgau says, “will get other people excited about it.”

Seventeen hundred miles to the east, they’re excited already. When EMS leaders from Nebraska learned of the Washington project at ImageTrend’s 2015 Connect Conference, they eagerly adopted the KPIs. As a condition of the NHTSA funding that enabled

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Some earlier work had preceded this, including a video course, and roughly doubled rates that had once been under 20% on both interventions. But there they stuck—until Donovan’s reports.

“Todd really brought in this CQI process, and we started com-municating as closely as we could with the services and evaluat-ing all those runs,” says Chip Cooper, NRP, head of research and quality management for the division. “By communicating what we found to the services, we really saw an improvement. We were able to put out a clear document: ‘Hey, we’re not doing this right. We know you’re treating the patients well; you’re just not putting it down, so it’s not obvious.’”

How it was implemented: Reports were distributed to every agency and service in New Hampshire. An accompanying video offered additional help with documenting aspirin, and information was included with rollout videos when protocols were updated, but it didn’t take much more than that.

An additional benefit was gaining some insight into why crews might not always document things like giving aspirin or perform-ing a stroke scale.

With stroke, one problem was the design of the run form: the location where you documented the stroke scale was in an odd, nonintuitive place—it seemed providers were just missing it. “We moved it to a really obvious place that was always available, and that helped a lot,” says Cooper.

With aspirin an issue was discovered with dispatch: New Hamp-shire has a statewide 9-1-1 PSAP, and as part of their EMD efforts,

the project, anything that results from the grants must be made available to anyone in the country.

How it’s worked: Ultimately this should all help measure, compare and improve EMS performance in key areas. But on a more basic level, it will provide a fuller and more thorough picture of what and how EMS in the state is doing.

“WEMSIS was always kind of incomplete because we don’t have a mandate to collect this data,” says Belgau. “So we were always strategizing on how to incentivize people to give us data. And one of the things we hear is, ‘Well, you’re not doing anything with the data.’ But it’s kind of a chicken-and-egg problem: You’re not giving us data that’s meaningful! We’re trying to get the data in there!”

Indeed, per numbers presented at last year’s Connect Conference, just 45% of all the agencies in Washington had ever reported data to WEMSIS, and just 23% in the pre-ceding six months. Most state systems are using ePCRs; they’re just not taking that extra step to send the data to the state. And with a dozen different vendors sharing the market, that’s a lot of siloed data that can only connect in WEMSIS.

Right now it generally falls to motivated MPDs to drive their system’s participation. Some are more motivated than others. By building the KPIs into WEMSIS, it allows agencies to take their own lead and do their own reports and comparisons. “They can put the data in and get the data out,” says Belgau.

Do the Right ThingThe problem: In New Hampshire state EMS leaders were dismayed to discover, in reviewing providers’ run data, that fewer than half of reports they examined docu-mented administration of aspirin to patients with cardiac chest pain. The rate was better than it had been a few years earlier, when the state established that as one of five key quality benchmarks for EMS systems, but it wasn’t high enough to leave anyone satisfied. The same was true of another key metric, performance of a stroke scale on potential CVA patients.

Were state providers really complying that poorly with their protocols? Officials with the state EMS division’s Trauma and EMS Information System (TEMSIS) doubt-ed it. Instead, they surmised, crews probably just weren’t documenting fully. They needed a way to help them do it better.

The solution: One fast and inexpensive answer was a series of reports, assembled from state data, to illustrate the problems and how to correct them.

“What we did was, using the plan/do/check/act cycle of CQI, put out fact sheets for the entire state—all the EMS provid-ers and service leaders—and showed them exactly how to document stroke scales and how to document aspirin appropriately in their incident reports,” says Todd Donovan, NRP, who led the project.

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Chip Cooper (left), Todd Donovan


statewide STEMI system. I ran one report, and in two weeks they came to me and said, ‘What can we do to fix this?’ I said, ‘Let’s develop some protocols.’”

How it’s worked: Those were drafted in two weeks and trialed for 18 months, and though EMS lacks the hospital out-come data to prove their benefit, anecdotal evidence told of success: MI patients were coming home faster, with stents instead of damaged hearts, and getting back to work. Instead of losing revenue, as they’d feared,

the critical-access hospitals benefited from a renewed faith in the system that helped business grow. The protocols subsequently went statewide.

“What we needed was the data, and we didn’t have the data in the early 2000s,” Rice says. “Once we got the system and started col-lecting data, it was easy to prove the point.”

RE FE RE N CE S

1. Krumholz HM, Herrin J, Miller LE, et al. Improvements in Door-to-Balloon Time in the United States, 2005 to 2010. Circulation, 2011; 124: 1,038–45.2. Diercks DB. American Heart Association Mission Lifeline: Developing a STEMI Regional Care System, www.emcreg.org/publications/monographs/acep/2009/acep2009_dbd.pdf.3. Nudell N, Rice D, Gale JA, Wingrove G, Bouthillet T. Rural acute myocardial infarction survey (RAMIS). International Paramedic Practice, 2013 Jan; 2(1): 3–10.

dispatchers there advised callers with cardiac chest pain to take aspirin. So some patients were taking it on their own before EMS arrival, and hence EMS wasn’t giving it.

Run forms also lacked any easy way to document a patient not getting aspirin for reasons beyond allergy—because they were unconscious, for instance, or had an oral issue that prevented it. The third version of NEMSIS, which went live in the state June 1, includes pertinent negatives to help clarify such issues.

How it’s worked: “It’s been unbelievable,” says Donovan. “Within 20 days we saw our aspirin administration rates go from the mid 40s to the 70s and finally to the 80s. And the same thing happened with stroke. Now we’re documenting aspirin administra-tion in the 84%–88% range. With the stroke scale we had similar results—documentation increased twofold.”

Bigger picture, it’s represented a step forward for EMS education throughout the state.

“It’s become a much more focused education process,” says Coo-per, “where we’re really getting right down to it and getting things back to the services. I think what it comes down to is that provid-ers, for the most part, want to do the right thing. They just don’t always know what that is.”

Quantif ying STEMI DelaysThe problem: “National progress has been achieved in the timeliness of treatment of patients with ST-segment–elevation myocardial infarction who undergo primary percutaneous coro-nary intervention.”

That was the happy conclusion of a 2011 review in Circulation.1 It cited a decrease in median door-to-balloon times from 96 minutes in the year ending December 31, 2005, to 64 minutes in the three quarters ending September 30, 2010. The percentages of patients with D2B times less than 75 minutes and less than 90 minutes both soared during the interval. And data within the piece showed the improvements occurring in rural systems as well as urban.

That didn’t sit right with Don Rice, MD, then EMS medical director for the state of Nebraska. “I’ve worked in rural areas,” Rice says. “I know many patients there are not seen in a timely fashion—there’s no way.”

Still, it was a claim he heard often—particularly from cardi-ologists and hospital executives who opposed a statewide STEMI system Rice was tasked with developing in the early 2000s.

Some deep data diving into the AHA’s data and Nebraska’s helped Rice rebut some of those claims of improvement and get the state’s system up and running.

The solution: The problem was, back in the days before direct transport to STEMI centers, patients could get delayed in small critical-access hospitals and not get the fast treatment they needed.

The AHA’s data told of overall D2B improvements, but if you looked closely, there were some catches. First, the way it counted the D2B interval started with arrival at the receiving hospital—it

carved out all prehospital time.2 And in documenting those rural improvements, it defined small hospitals as having up to 300 beds.1

“In Lincoln,” notes Rice, “all three hospitals have fewer than 300 beds. So in this urban environment, all of those would be considered small hospitals.” Lumping very small hospitals in with hospitals like those, he contended, skewed the results and masked poor performance at those very small ones.

Third, rural hospitals accounted for just 6.8% of the almost 900 hospitals the study looked at. But in Nebraska, they account for roughly a third of all hospital beds. And fourth, in supplemental material for the study released later, it was revealed that more than 50,000 STEMI cases were excluded from analysis for reasons like missing inital EKG interpretations or other key data elements.

“If you have a heart attack patient and limited staff, your time is best spent to get

the patient out as quickly as possible,” Rice says. “So a lot of times rural docs will send an EKG. But maybe they didn’t have a chance at the copy machine to quickly sign the EKG. And if they didn’t do that, it didn’t get included in this study.

“My point is that many of the things that happen in a rural envi-ronment are also the very things that make you get excluded from the American Heart Association data. If you look at the reasons why they kicked people out, it would disproportionately affect rural hospitals. So what I’m seeing is a large skewing of data.”

To convince the doubters, Rice conducted a grassroots survey of Nebraska’s 65 critical-access hospitals, which was eventually pub-lished as the RAMIS study.3 AHA reps maintained those hospitals all had thrombolytic policies, an accepted alternative at the time for STEMI patients seen at facilities not capable of PCI, and stand-ing transfer agreements with PCI-capable hospitals. The RAMIS survey found:

» While 98% of critical-access hospitals had thrombolytic poli-cies, 23% said they had providers who “trend(ed) toward not admin-istering thrombolytics.” Just 60% could definitively say they didn’t.

» Just 45% said they had standing transfer agreements with regional STEMI centers.

Paramedics in the state echoed the claim that getting STEMI patients to cath labs could take hours, so Rice also crunched some state data. The math was pretty straightforward: He took one well-reputed hospital, then looked at all the patients taken there for cardiac issues. Subtracting their arrival time from their departure time revealed how long they were staying.

“The average for a heart attack patient,” Rice says, “was 4½ hours! Now you understand why this was so important.”

How it was implemented: At the hospital they were shocked and abashed. They didn’t know the delays were happening or that you could even have standing transfer arrangements. Within a matter of weeks, work began on the statewide STEMI system.

“I was able to use the database system to prove patients were lingering in ERs and not getting treatment,” Rice concludes. “I’d been fighting politicians and cardiologists for 10 years to create a *For terms and conditions please visit www.buyemp.com/customer-service.html

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Don Rice, MD

The Hooley Awards are given in conjunction with ImageTrend’s Connect Conference. This year’s events, with another set of winners, will be held July 20–22 at the RiverCentre in St. Paul. For more information on the Connect Conference, see www.imagetrend.com.

Figure 1: Findings From the RAMIS Study

TECHNOLOGY RESOURCE GUIDE


21st Centur y Problem SolvingEvolving technologies are changing the way we communicate

Digital EMS Technolog y Delivering Protocols on DemandTechnology has not only enabled medical advances, but it

has changed the way we deliver protocols and communi-

cate information to practitioners. A decade ago paramedics

were still referring to outdated, cumbersome manuals for

protocols, costing time that could mean a patient’s life. With

digital apps that provide protocols, that’s no longer the case.

By delivering protocols through mobile devices, protocol

updates can be pushed out in real time rather than batch

updates. If there is a medication shortage or new research

that warrants a change in procedure, updates can be quickly,

dynamically and consistently pushed to every provider.

“The ability to distribute our protocols to our providers

electronically, with accessibility in both on- and offline envi-

ronments, has had significant value,” says John Lyng, MD,

medical director of North Memorial Ambulance & Air Care

of Minneapolis, MN. “Before we began using digital mobile

protocol delivery, we had to generate printed protocol books

for each of our providers and it was impossible to provide protocol updates to each pro-

vider simultaneously or to ensure that each provider was even using the same version of

our protocols.

“The use of digital applications like Acid Remap’s PPP has allowed us to push out simul-

taneous updates to every provider, with automatic updating for every device upon the next

time the user opens the application. Now we can provide more resources at the swipe of

a finger than we were previously able to provide in a printed format. This technology solu-

tion has helped improve access to information and the quality of care our crews provide.

The application is an invaluable tool and has become mission-critical in our operation.”

1st Minute Mobile AppWhat is it?The 1st Minute mobile app allows EMS providers

to more easily communicate with patients when a

language barrier exists. The app allows providers

to communicate with the patient by using transla-

tion technology in order to reduce guessing by first

responders, which simplifies the process of getting

basic details form a foreign language speaker. The

app is available for both Android and iOS systems.

How do I use it?When a language barrier is present between pro-

vider and patient, the provider can use the 1st

Minute mobile app to help communicate. After

downloading the app, providers can give the device

to the patient to select a language. Once the lan-

guage is selected, the patient answers questions in that lan-

guage including what symptoms they are experiencing, select-

ing pain location and entering essential medical information.

Once that information has been provided, the

app translates it back into the language of the

provider.

What are the benefits?The app allows for quick and easy assessment even

when a language barrier is present. Because the

app has a pre-populated language database, no

internet connection is required for use. The goal of

the app is to facilitate the entire conversation in less

than 60 seconds, so patient care isn’t compromised

by clunky conversation. The combination of mobile

technology and patient care is forward thinking for

the future of EMS.

Where can I learn more?To learn more about the 1st minute mobile app, visit 1stminuteapp.com or find the app in the App Store or on Google Play.

Sof tware Resolves Internal Audit Issues for WA A gency

When Skamania County (WA) EMS hired

a firm to conduct an audit they discovered

they could resolve many issues by imple-

menting Aladtec, an online employee

scheduling and workforce management

software system.

“The audit resulted in 57 areas of

improvement. By using Aladtec, I’m satis-

fying multiple areas, including staff sched-

uling, fleet maintenance, accident reports,

training logs, consumable medical supply

tracking, shift logs...the list goes on and on,”

says Skamania County EMS Chief Patrick

Nicholson.

For example, Nicholson created a vehi-

cle repair form. When it’s submitted, the

vehicle maintenance captain receives a

text and e-mail notification there’s a repair

request. Information fields on the form

request specific data that can be exported

to Excel, separated by vehicle and a report

generated to see how much each vehicle in

the fleet is costing in repairs and preventa-

tive maintenance.


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Searchable Helispot Databa se Improves SafetySafety is paramount in the EMS indus-

try, especially when air ambulances are

involved. To help improve and aid safe

operations, Protean created the LZCon-

trol database.

LZControl is a free database that allows

for greater communication and safety in

the air ambulance community. The pro-

gram includes a searchable helispot data-

base with contact information, coordinates

and IFR information.

The database’s maps have satellite

images of air ambulance destinations and

provide full zoom control and the ability to

upload your own images. LZControl also

provides weather reports from nearby sta-

tions and, if necessary, gives users alter-

nate landing sites, precision approach

information and more.

The information in the archive is crowd-

sourced through users and cross refer-

enced to ensure accuracy. Registered

users, once verified by the company, can

provide updates to existing landing zones

or create new entries. Crowdsourcing the

information for the landing zones also

allows users to see updates in real time.

Users can also submit photos to supple-

ment the satellite map and provide more

context for pilots to use as they approach

the landing zone.

Site-specific contact information is pro-

vided for users as well, so air ambulance

crews can easily find and utilize phone

numbers or radio frequencies if necessary.

The main beneficiary of this program is

air ambulance crews who need to find a

place to land.

“Landing in a location that no one has

ever landed a helicopter in before, espe-

cially at night, is one of the most challeng-

ing things you can do,” says Mark Bohn, one

of LZControl’s three developers, in a 2014

interview with ROTOR Magazine. “We rely

on a lot of resources and years of experi-

ence to make sure the scene remains as

safe as possible.”

The database also includes possible haz-

ards at each landing site so air ambulance

pilots know what to look for when landing

their craft, again putting an emphasis on the

safety of the pilot and crew.

LZControl was launched in 2013, and has

since amassed more than 4,000 entries

in the landing zone archive and was given

the Airbus Helicopters Vision Zero Aviation

Safety Award in 2014. The award helps pro-

mote safety in the air medical industry and

recognizes companies that have demon-

strated a commitment to aviation safety.

LZControl is available to users across

the United States. In the future, LZControl

plans to expand to include landing zones

outside the United States. For more, see

LZControl.com.

Online Databa ses Aim to Improve Resource AccessAggregation of resources is a concept we

all learn and practice to a certain degree,

but it is rarely done on a large scale. The

internet has brought us to the point where

we feel we can find whatever we need

whenever we want. The problem is much of

this data is difficult to locate or inaccurate.

So where do agencies turn when they

need equipment, personnel or resources

they are unable to source locally or are

unsure how to find? The National Emer-

gency Resource Group is creating a series

of online databases to allow emergency

services to find such resources for both

day-to-day operations, as well as mass

casualty events.

See emergencytransportassociation.com and nationalemergencyresource group.com.

Meet the Health Data E xplorersThe Health Data Exploration project,

undertaken by the California Institute for

Telecommunications and Information

Technology with support from the Robert

Wood Johnson Foundation, is shaping the

way healthcare uses

health-related data.

With a surge in

ways to track individ-

ual health and fitness

data wearable devices

such as Fitbit or smart-

phone apps, more data

is becoming readily

available. Research-

ers from UC San Diego

and UC Irvine believe

this data, and other

information collected

in a more passive manner such as through

social media, can fill in gaps that are left

by more traditional health data collec-

tion methods and give healthcare provid-

ers a broader, more complete picture of a

patient’s health.

Individuals can join the network to pro-

vide this data to researchers and compa-

nies, who in turn study the information

NationalEmergency ResourceGroup

and use it to discern better ways to treat

patients or create more helpful health-

related devices and apps.

For EMS personnel, health data can be

key in providing effective and efficient

patient care. EMS pro-

viders can get a more

well-rounded picture

of a patient, such as a

detailed medical his-

tory, a better look at

the physical fitness of a

patient and more infor-

mation on the everyday

lifestyle and behaviors

of patients.

The EMS system

currently uses health

data to influence

research and determine the best patient

outcomes, and initiatives such as the

Health Data Exploration project aim to

provide more of this data for healthcare

providers.

For more information on the Health

Data Exploration project or to take a look

at some of their research, visit their website

at hdexplore.calit2.net.

©iStockphoto.com/Hong Li



Why EMS Must Be Par t of Health Information E xchangesThe Affordable Care Act (ACA) highlighted a few glaring deficien-

cies in the U.S. healthcare system, namely around data exchange

and information sharing. Following the ACA’s passage, hospitals,

doctors, labs, clinics and other traditional healthcare providers

scrambled to figure out how the provisions requiring data sharing

would be implemented.

Fast-forward to the present. Health information exchanges

(HIEs) are all over the country, each trying to stay ahead of the

regulations that many are just now beginning to understand. Hos-

pitals are starting to share more information with each other, labs

and clinics are participating, and doctors are beginning to have bet-

ter information with which to treat patients. Despite these efforts,

there is a huge piece that is missing from the equation that many

people still fail to recognize—ambulance data.

What’s perplexing is that, according to the National EMS Infor-

mation System (NEMSIS), more than 75% of U.S. states already

have an electronic storage system that houses this data—a system

conceptualized over 15 years ago. These systems vary across enti-

ties, with differing levels of complexity.

Data is derived from local EMS providers contributing informa-

tion to their respective state healthcare registries (generally man-

aged by Health and Human Services in some form), ultimately to

be used for analysis to improve care provided by paramedics and

emergency medical technicians on the street. However, despite

the maturity of the model and its contribution to better patient

outcomes through research and analysis over the long term, short-

term issues persist.

EMS agencies must build on this effort and become a more

formalized part of the exchange of patient data, not just in the

reporting and collection of data. This exchange occurs between

emergency departments, physicians and EMS providers in only a

few parts of the world (e.g., United Kingdom), but severely lags in

most other mature markets, such as the U.S., Australia and Can-

ada, among others. Every local government provides EMS service,

whether public, private or volunteer. It’s a core community service

that we all depend on when we are at our most vulnerable. As

such, every local government is effectively a healthcare provider,

similar to a hospital or clinic. So why are EMS providers continually

overlooked in the HIE equation? Perhaps it’s because they are the

smallest “cost” in the healthcare chain, or maybe because they

don’t have the “voice” of hospitals and health insurers?

Considering the positive implications of collaboration throughout

the continuum of care, the current state of information sharing

is problematic. Data information exchange platforms, like ones

used by hospitals across the globe, are not exclusively for hospi-

tals, physicians, labs and clinics. These tools provide an avenue

for local governments to connect to HIEs, providing them instant

operational and strategic value. Combined with the data that is

already being collected, using these tools, EMS providers can:

» Give paramedics real-time access to critical patient informa-

tion including allergies and serious health conditions before they

arrive on scene.

» Equip the new breed of paramedics, sometimes referred to

as advanced paramedics or community paramedics, with detailed

patient information as they conduct home visits following a patient

discharge from the hospital.

» Enable data sharing between EMS agencies during mass

casualty events, ensuring patients are provided optimal care during

difficult disaster situations.

Ultimately, EMS is healthcare, and EMS agencies can provide

tremendous value to the HIE equation because they are often the

conduit between spokes in the giant healthcare wheel.

Kurt A. Steward, PhD, is vice president at Infor.

Hybrid Devices Of fer Fle xibilityIn order to improve efficiency and patient care,

many agencies have transitioned from pen

and paper systems to mobile solutions. Mobile

devices allow EMS providers to capture lifesaving

information and easily communicate with other

healthcare professionals. It is critical for agencies

to select reliable technology that can operate in a

range of extreme environments.

Today’s marketplace is filled with “ruggedized”

mobile device options. Laptops built to withstand

the bumps and vibrations of an ambulance ride can

be mounted in-vehicle or lightweight rugged tablets

can be easily carried during a full shift.

However, there is no “one size fits all” when it

comes to mobile devices. While tablets have

become popular, many still require some of the

functionality provided by laptops that tablets

don’t always offer, and vice versa. For example, EMS providers may

prefer tablets for easy portability as they move in and out of vehi-

cles while evaluating patients, but the convenience of a keyboard

is clear when it comes to entering lengthy patient treatment notes.

The increased functionality and flex-

ibility of a hybrid solution is an attractive

option for those who want the best of

both worlds. When responders arrive on

scene, using their device in tablet mode

allows for easy capturing, sharing and

checking of critical information. During

transport to a hospital, they may also

need to use video streaming to con-

ference with emergency room doc-

tors. Once the patient transport is

completed, in order to finalize their

reports, EMS workers need to perform more text-heavy tasks that

require a keyboard. Given the variety of locations first responders

may be called to on any given day, they can benefit from in-vehicle,

tablet and laptop functions.

Detachable laptops, like the Panasonic Toughbook 20, have been carefully architected to be used in various modes.

In this case review, the authors discuss the difficult intubation of a patient with ankylosing spondylitis.

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In this article the authors interview Andrew Bowman, MSN, RN, ACNP-BC, an acute care nurse practitioner and paramedic in Indiana. Andrew recently faced a difficult intubation situation with a patient with CHF complicated

by severe kyphosis secondary to ankylosing spon-dylitis. Patients with ankylosing spondylitis present extremely difficult intubation challenges. Andrew discusses his approach and how he was able to suc-cessfully intubate this patient.

Gene: Jason, what is ankylosing spondylitis and what are the difficulties faced when you have to intubate a patient with this condition?

Jason: Ankylosing spondylitis (AS) is one of a group of disorders that are related to rheumatoid arthritis. We have discovered genes that give you a predisposition to it, but it’s not a truly hereditary disease—it seems to be more of a body’s overreaction to an infection.

AS chronically inflames the tendons and joints of the axial skeleton. For whatever reason, it likes to go after the sacroiliac joint first and the spine sec-ond. Like other rheumatoid diseases, patients can get

flare-ups of AS, and have a greater or lesser degree of symptoms in between flares. Having AS also puts patients at increased risk for stroke.

As the tendons get inflamed, they develop bony growths that make the AS patient’s spine very stiff and painful, making airway positioning difficult. The bones can become weakened and develop com-pression fractures, to the point where the patients will develop a severe kyphosis, as we will see with Andrew’s patient. The bones are so weak that if this happens even a neck manipulation as innocuous as putting a cervical collar on these patients can be quite dangerous. There is actually a case report of a 59-year-old man’s spine being fractured by applica-

By William E. “Gene” Gandy, JD, LP, Steven “Kelly” Grayson, NREMT-P, CCEMT-P, & Jason Kodat, MD, EMT-P

As this challenging case demonstrates, planning

ahead is key to mastering the difficult airway

Steven “Kelly” Grayson is a featured speaker at EMS World Expo, Oct. 3–7, in New Orleans.

Figure 1: Slice from patient’s prior admission CT scan demonstrates his severe kyphosis.


Jason: What were your thought processes as you formulated the next steps to try to intubate this patient?

Andrew: At this point I had a patient who was sedated and with hypercapneic respira-tory failure who clearly needed an airway. As noted earlier, his anatomy would have made any approach such as cricothyrotomy or retrograde intubation difficult. We reap-plied the BiPAP and continued his high-flow nasal cannula oxygen as I formulated my back-up plan.

Kelly: Had you ever had to deal with a patient like this before?

Andrew: I have intubated the patient with moderate kyphosis from ankylosing spon-dylitis before, but not to the degree that this patient was exhibiting.

Gene: Can you describe your GlideScope technique and how it differs from “normal” approaches to intubating?

Andrew: The GlideScope allows us to “see around corners” so that we do not need to have that perfect alignment of multiple air-way axes to pass an endotracheal tube. I do follow the recommended approach where I look into the mouth as I advance the GlideScope. I then transfer my attention to the video screen until the glottic opening appears and then bring the endotracheal tube into the right side of the mouth with the tube pointing at the 3 o’clock position. I then rotate the tube as I advance it, so that it is now at the 12 o’clock position, and it is typically perfectly aligned with the glottic opening at this point. It is then just a mat-ter of advancing the tube and removing the stylette.

Jason: How did you position the patient for your next try and why you did that?

Andrew: As you can see from Figure 2, recreated using one of the excellent emer-gency nurses I have the pleasure of working with, we elevated the entire bed so that the head could be dropped into a Trendelen-burg position, while keeping the head of the patient’s bed actually elevated to help support his kyphotic upper body.

tion of a rigid cervical collar, which led to spinal cord injury and his eventual death.1

In other words, you have to intubate these patients with their necks in the position you find, not the position you want.

Gene: Andrew, please describe the patient who presented to you.

Andrew: This was a mid-40s male who lives with his parents and brother at home. I had admitted him to the hospital two weeks prior with pneumonia. He required BiPAP treatment during that hospitalization for hypercap-nea (CO2 retention) secondary to severe restrictive lung disease from his severe kyphosis secondary to his ankylosing spondylitis. He also had a history of hypertension, diabetes, GERD and necrotizing fasciitis.

On this presentation he was awake and complaining of “feeling sick.” He seemed fatigued, would not keep his eyes open and would not elaborate further on his symp-toms. His family reported they noticed fever at home and some labored breathing. He was also reportedly hypoxic at home, where he was on supplemental oxygen at 5 lpm via nasal cannula and he reportedly desaturated to 56%, although in ER he was hovering around 90%–91% with his supplemental O2.

On arrival he was afebrile, with a heart rate of 110, respiratory rate of 22 and slight-ly labored, and blood pressure elevated to 180/90. Breath sounds were diminished bilaterally without obvious wheezing or rales or rhonchi. JVD could not be well assessed as he could not extend his neck from a chronic f lexed position. Heart sounds were heard without murmur. Skin was pink, warm and dry. Abdomen was soft and there was no guarding or tenderness. There was 2+ bilateral pre-tibial edema without calf tenderness. His family reported that his legs had been edematous since last discharge from the hospital.

We established IV access, continued O2, obtained an EKG, sent off labs and obtained a bedside chest x-ray.

Figure 1 is a slice from his prior admis-sion CT scan that demonstrates his severe kyphosis.

Kelly: That’s some pretty pronounced kyphosis! Andrew, what immediate chal-lenges were you faced with when you first saw this patient?

Andrew: My initial differentials included CHF, recurrent pneumonia, other infectious causes, recurrent hypercapnia, acute intra-cranial event (bleed or CVA) and metabolic disorders. I had concerns that if he needed an airway intervention, his anatomy would make this a challenge.

Kelly: Half the battle of airway manage-ment is anticipating problems and being prepared. So how did you approach this patient initially?

Andrew: His head CT was unremarkable. His chest x-ray was concerning for low lung volumes, CHF and bilateral pleural effu-sions. He did have an elevated proBNP (a marker for CHF) and an elevated troponin, but his EKG did not show any evidence of ischemia/STEMI, so I was concerned that his hypertensive CHF was causing a tro-ponin leak.

He remained hypertensive and dyspneic, so we drew an arterial blood gas (ABG) and then started BiPAP and nitroglycerin infu-sion for my working diagnosis of hyperten-sive CHF. His ABG showed severe hypercap-neic respiratory failure with a pH of 6.98, PaCO2 of 202 mmHg, and PaO2 60 mmHg.

I had a discussion with his mother and other family members present about the possible need for intubation and his mother indicated that at his most recent prior hos-

pitalization, the patient had talked about intubation and mechanical ventilation with his pulmonologist and had decided that he did not want this done. However, I could not find that information in the medical record.

I then approached the mother and family again, indicating that it was my concern that if we did not intervene with more aggressive airway and ventilation management, the patient would likely die from his hypercap-neic respiratory failure. After 45 minutes, a repeat ABG showed worsening respiratory

failure with pH of 6.96 and PaCO2 of 214 mmHg, but PaO2 was better at 90 mmHg. It was at this point that the mother requested I proceed with intubation.

My plan was not to chemically paralyze this patient. I wanted to try and preserve his respiratory drive as much as possible since we could not lay him flat to do bag-mask ventila-tion. My plan was to use ketamine for sedation, with BiPAP continued for ongoing oxygenation, and to add high-flow nasal cannula oxy-gen using Dr. Richard Levitan’s NO DESAT (nasal oxygen during efforts securing a tube) approach to main-

taining oxygenation during the intubation attempt after BiPAP was removed. I was going to use the GlideScope video laryngo-scope as again, I would not be able to extend his head and neck to use direct laryngoscopy. In addition, I thought I might try to approach from the front, as he could not lay back, and insert the GlideScope like a tomahawk.

Unfortunately, even though I had a great view of the vocal cords using this approach and his oxygen saturation was well maintained, I could not navigate the tube through the vocal cords.

Jason: Why do you think you had difficulty getting the tube to pass through the cords?

Andrew: I think it comes down to muscle memory. Clearly I have been intubating using direct laryngoscopy for 30+ years and have been using GlideScope video laryngos-copy for five years, so I have great experience with this. However, I have rarely used the tomahawk approach, and I could not flip the technique in my mind to properly rotate the tube where it needed to be.



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While we maintained sup-plemental oxygen using BiPAP and high-flow nasal cannula oxygen, I positioned myself at the head of the bed and stood on a step stool so that I was above and behind the patient to bet-ter visualize placing the Glide-Scope and tube into the mouth.

Using a hyperangulated Gli-deScope blade I was able to eas-ily place the GlideScope in the mouth, and as I advanced it, I was afforded a perfect view of the glottic opening.

Since this is typically fairly close to the position I would use for regular intubation, it was just a matter of advancing the tube and it went in very easily. In retro-spect, I should have started with this technique and approach.

Gene: Did you consider using a bougie, and why or why not?

Andrew: The typical bougie does not work very well with the GlideScope. However, I did have it available in case a standard approach did not work.

Gene: If you had not been able to get the tube in with the Gli-deScope, what other measures could you have considered?

Andrew: If we had not been successful, we did have a cri-cothyrotomy tray and a retro-grade intubation kit, as well as a supraglottic airway available to facilitate airway management.

Jason: Obviously this is a rarely occurring presentation. What advice do you have for medics who have never seen this but want to be prepared in case it ever presents to them?

Andrew: Understand that with someone with severe kypho-sis from any cause, using a standard direct laryngoscope

approach would be very dif-ficult if not nearly impossible. This is a classic scenario where video laryngoscopy is superior to direct laryngoscopy for air-way management.

Conclusion The key to being ready for a patient like this is to practice ahead of time. Set up a manikin with its neck hyperflexed and practice different approaches and techniques. The time to think about these cases is before you are presented with them. At least, if you have practiced a few times and repeat practice at decent intervals, you won’t be taken completely by surprise when it happens to you.

RE FE RE N CE

1. Clarke A, James S, Ahuja S. Ankylosing spondylitis: inadvertent application of a rigid collar after cervical fracture, leading to neurological complications and death. Acta Orthop Belg, 2010 Jun; 76(3):413–5.

ABOUT THE AUTHORS William E. “Gene” Gandy, JD, LP, has been a paramedic and EMS educator for over 30 years. He has implemented a two-year associate degree paramedic program for a community college, served

as both a volunteer and paid paramedic, and practiced in both rural and urban settings and in the offshore oil industry. He lives in Tucson, AZ.

Steven “Kelly” Grayson, NREMT-P, CCEMT-P, is a critical care paramedic for Acadian Ambulance in Louisiana. He has spent the past 22 years as a field paramedic, critical care transport paramedic, field

supervisor and educator. He is a frequent EMS conference speaker and author of the book En Route: A Paramedic’s Stories of Life, Death, and Everything In Between and the popular blog A Day in the Life of an Ambulance Driver.

Jason Kodat, MD, EMT-P, has been in EMS for more than 15 years. He has reviewed EMS textbooks and the USFA’s EMS Medical Director Handbook, and lec-tures at regional EMS con-ferences regularly. He cur-

rently works as an emergency physician and associate EMS medical director at hospitals near Pittsburgh, PA.


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With someone with severe kyphosis from any cause, using a standard direct laryngoscope approach would be very difficult if not nearly impossible. This is a classic scenario where video laryngoscopy is superior to direct laryngoscopy for airway management.


Not all of us in EMS spend our careers working in ambulances. Nontraditional positions offer EMTs and paramedics experience away from the 9-1-1 world. If lights and sirens aren’t essential ingre-

dients of your ideal job, you might thrive in indus-tries where patient care is ancillary to the primary business.

Last month we reviewed EMS opportunities in the entertainment and hospitality fields. The emphasis on maturity and people skills is echoed this month by colleagues serving in international, industrial, hospital and laboratory settings.

InternationalHave you ever needed a change of scenery? Paramedic Mark Mosier of Kelso, WA, did, so he moved.

To Iraq.“After I took early retirement from the fire depart-

ment,” Mosier says, “a buddy of mine told me about a London company, Frontier Medical, that places paramedics and nurses in underdeveloped locations all over the world. That sounded pretty cool, so I e-mailed them my résumé. Twenty minutes later I had a three-month contract and reservations for a flight the next day.”

After a 13-hour trip to Istanbul and a stop-over in Dubai, Mark landed in Basra, Iraq.

“I had no idea what to expect, but I could tell right away I wasn’t in ‘Kansas’ anymore. Iraq has abject poverty. There’s sand everywhere, nobody speaks English, and people are very cautious around you. My biggest fear had nothing to do with violence; I just wasn’t sure I was the right person for the job.”

Mosier soon discovered there were plenty of ex-

pats from the U.S. and U.K. who could help him adjust to Iraqi culture and customs.

“You have to be careful; you don’t want to cause an international incident by saying or doing the wrong thing. You need to constantly be aware of your situation—where you are and whom you’re around. It sounds nerve-wracking, but it’s also exciting.”

After Mark was introduced to his work environment—an oil-drilling compound with about 100 prospec-tive patients—he began to realize he’d be operating much more independently than most stateside medics.

“It’s not really a job for novices,” he says. “You’re a million miles from home, you’re not in your own bed and nobody speaks your language. You worry you bit off more than you can chew. I think you should have at least 10 years in EMS with a variety of calls in diverse communities before working abroad. You have to be very comfortable with your clinical skills. There are protocols but no real back-up. The closest hospitals for foreigners were in Jordan and Dubai, so I was expected to treat as much as I could on site.

“Very few people came in with critical illnesses or injuries. The first patients I saw were complaining of chronic headaches, nausea, knee pain—things like that. It was more like running a clinic than doing true EMS.

“You wear different hats—you’re a counselor, a friend. You’re dealing with a pretty fragile community where people see doctors for cut fingers and head-aches. I had to dial back the urgency I’d gotten used

By Mike Rubin

PART 2

If you’re tired of the 9-1-1 grind, opportunities abound for delivering nontraditional EMS

to when I was treating really sick people in a 9-1-1 system.”Despite the cultural differences, Mosier feels the pros

of working internationally outweigh the cons.“The travel is exciting; you’re going to places you’d nor-

mally never have a chance to see. You’re making good friends with unique people from all over the world. It gives you a bit of hope for humanity.

“The pay was great—anywhere from $300 to $500 a day for a seven-day work week. That could be $15,000 a month! They just send it to your bank. I stayed on and before I knew it, my three-month contract had turned into three years.”

HospitalYou’re no stranger to hospitals if you work 9-1-1. There’s a difference, though, between delivering patients to emer-

gency departments and receiving them there. Kentucky paramedic Kevin Hurley has done both.

“I started at Crittenden County (KY) Hospital 15 years ago, right after I became a medic,” he says. “I stayed until they eliminated my position in 2012. Now I’m back on an ambulance full time.”

According to Kevin, the biggest difference between hos-pital and prehospital environments is the patient backlog.

“You have calls holding in 9-1-1, but the patients aren’t right there in your face. In the ED, they’re all sitting in the waiting room.”

Nonemergent cases clog the ED as much as they do EMS. Sometimes that means hospital paramedics have little or no supervision.

“One time the ED physician was handling a code on another floor when a second code came in,” Hurley says.

In part two of this feature, columnist Mike Rubin discusses four more nontraditional EMS jobs.


“I got to work that arrest just as I would have in the field, except I had a couple of extra people helping me.

“In the ED, I could do whatever I did in the field including some procedures, like chest decompressions, the nurses couldn’t do. There were also things like hanging anti-biotics that I was allowed in the hospital but not in the field.”

Hurley recommends at least a year of 9-1-1 experience before transitioning to an emergency department. He says job satis-faction depends as much on attitude as it does in the field. “You can’t go into the ED with a God complex. It might be hard to get used to nurses signing for what you do, but you have to look at it as a learning experi-ence and not get adversarial. Adjusting to hospital work isn’t so bad; maybe go back and study pharmacology a bit more because giving meds is such a big part of the job.”

Medic wages at ERs vary, but they’re usu-ally close to 9-1-1 rates. Benefits for full-timers can be much more robust than at private ambulance services.

IndustrialWhen you’re half of a two-person medical team in a 1.3-million-square-foot facility, looking after employees’ mostly nonemer-gent needs often requires more business experience than therapeutics.

“It’s quite an adjustment from 9-1-1,” says paramedic Alan Keith, onsite medical rep-resentative at Amazon.com’s spacious Leba-non, TN, warehouse. “We have a clinic with basic first-aid stuff and OTC meds only. If we get anything serious we call 9-1-1.”

Keith was on the receiving end of those calls for 14 years. Moving to industrial med-icine has been quite an adjustment for him.

“You have to change your whole mind-set,” he says. “It’s a lot less aggressive, a lot less stressful here, but you can’t ever lose sight of the fact that the company’s primary business is to get products out the door as quickly and efficiently as possible.

“Mostly, my department looks for ways to improve employee safety. We also han-dle worker’s comp, which requires lots of administrative time. Still, medical experi-ence is important because you’re dealing with day-to-day injuries and treatment.”

Not being able to offer advanced care can be frustrating for long-time paramedics.

“I don’t think this is a position for some-body new to EMS,” Keith says. “Ideally, you want someone with field experience who’s already gotten 9-1-1 out of their system. You’re dealing more with chronic condi-tions than emergent cases.”

Salaries are comparable to other EMS jobs but big-company benefits, like tuition assistance and retirement plans, can make the corporate world seem awfully attractive.

“One of the girls I work with just com-pleted paramedic school with financial assistance from Amazon,” Keith adds.

LaboratoryAttention EMS providers: An international blood-products processing firm has open-ings for paramedics. The problem? I can’t mention the company’s name. I had to agree to that condition in order to interview their staff, but that doesn’t mean you can’t Google “plasma donation.” That’s the principal business where Brittiney Krahn works as training development coordinator.

“We hire paramedics and nurses to screen prospective donors, collect their blood and process it through phoresis machines,” says Krahn, 29. “It’s a booming business. We have over 100 locations in the U.S. alone.”

Krahn says she prefers to hire paramedics because of their sense of urgency.

“Medics are quicker to respond, quicker to catch problems when they’re evaluat-ing donors. They’re not just going through the motions; they’re communicating with prospective customers and understanding their stories.”

Rob DeMeo, who worked for Krahn for a year between traditional EMS jobs, says the plasma donation industry was a completely different experience for him.

“You’re not dealing with patients—not in the conventional sense. They’re customers,”

the 37-year-old paramedic says. “They come through the door because they’ve heard they can make money donating their blood, but they’re still apprehensive about getting stuck with 17-gauge needles.

“You have to be prepared for ‘donor reac-tions’: people vagaling down, even seizing due to pre-existing conditions. I never had anything life-threatening, but I did call 9-1-1 a few times.”

DeMeo liked being able to keep a regular schedule. Working in a climate-controlled facility wasn’t bad, either.

“It’s a stable environment,” he says. “You’re out of the weather and you don’t have to worry about getting hit by a car at a wreck on the side of the road. You even get to finish lunch.”

DeMeo admits he missed having a partner, but felt fairly comfortable a few weeks after starting. His compensation was similar to 9-1-1 with even better long-term prospects.

“I became a supervisor within four months, then was offered a traveling position training company employees in 48 states. How many EMS jobs can match that?”

Looking BackThe occupations we’ve examined in our two-part series are representative of para-medic and EMT opportunities in nontra-ditional environments. Experiences with individual employers vary, just as they do in 9-1-1. However, after serving in five of the seven profiled industries, I’d say a common, significant advantage those jobs have over conventional EMS is the lower stress—men-tal and physical—of mostly nonemergent responsibilities.

If the prospect of high-energy critical care is what gets you out of bed for another shift, stick with 9-1-1. But if you’re person-able, mature, customer-oriented and well-versed in well care, you might find “alterna-tive EMS” a nice way to broaden and extend your career.

ABOUT THE AUTHOR Mike Rubin is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at [email protected].

Salaries are comparable to other EMS jobs but big-company benefits, like tuition assistance and retirement plans, can make the corporate world seem awfully attractive.

What EMS Leaders Can Learn From Admiral RickoverSeven principles guided this longest-serving naval officer to success

Admiral Hyman Rickover is known as the

“Father of the Nuclear Navy.” He began

his Navy career in 1918 and was forced

into retirement in 1982. With 63 years of

service, he was the longest-serving U.S. naval

officer. His main achievement was becoming

the first admiral to oversee the implementation

of nuclear propulsion in the U.S. Navy for sub-

marines, cruisers and aircraft carriers. His team

designed, engineered and built the U.S. Navy’s

first nuclear submarine in three short years. He

oversaw this program for 30 years.

Admiral Rickover had many successes during

his career in the Navy. The U.S. Navy has a tre-

mendous safety record when it comes to nuclear propulsion on its

ships. There has never been a major accident involving a nuclear-

powered ship because of the reactor. Two nuclear-powered subma-

rines have sunk in the Atlantic, but not because of a nuclear accident.

This safety record is no fluke. When you think about your high-risk

EMS system, there are many similarities.

Admiral Rickover had seven principles that guided him to suc-

cess. EMS managers can use many of these principles to lead their

systems effectively.

First, Admiral Rickover believed employees should exceed the

minimum standard. He did not believe in the status quo. If you’re

just meeting standards, you cannot be outstanding. He believed

employees and organizations should always look to improve.

Another principle he followed was that employees who operate

in complex systems should be highly capable. This certainly applies

to EMS systems, where life-and-death decisions are made by your

employees daily. Unfortunately, we all know or have worked with a

provider whom we feared would treat us if we were in an accident.

Conversely, we have all worked with or know providers whom you

would want to look up and see if you were seriously ill or injured.

Another Rickover principle was that managers should accept

bad news when it comes and deal with it head on. He believed that

the success or failure of systems was

because of the manager or supervisor

leading them. If something failed, he felt

it was the supervisor or manager who

was not capable of managing their area.

Bad news should be handled directly

with the removal or demotion of the

manager or supervisor. Do you as the

EMS manager currently have supervi-

sors or managers working for you who are keep-

ing your EMS organization from reaching its full

potential?

Admiral Rickover also believed you should not

dismiss the risks and dangers associated with any

job. This is especially true in EMS, where inherent

dangers are everywhere, including harm to our

employees from accidents, assaults by patients and

infectious diseases to name a few. But there are

also risks including theft, lawsuits and reputation

damage to the EMS organization through negative

publicity.

Admiral Rickover was a major proponent of con-

stant training. In EMS, training should happen every

day—even if just to review a medical protocol or drug. As I like to say,

professional athletes practice and train every day and they know

when game time is and what the field will look like. On every EMS

call, you do not know the game time or what the field is going to

look like. As an EMS manager you should ensure your employees

have training constantly available to them, but not the kind where

they just sit in a classroom enduring death by PowerPoint to get

CEUs for relicensure like I have seen in several EMS organizations.

Another principle of Admiral Rickover’s was that organizations

should learn from their mistakes. He would say, “Success teaches

us nothing; only failure teaches.” As an EMS manager you should

continually look at data and see where failures in your organization

are occurring. Many EMS managers see mistakes as embarrassing

or somehow a failure of their leadership. If there is something that

goes wrong, you should embrace that mistake and learn what can

be done to prevent it from happening again.

One final principle of Admiral Rickover was that systems should

be in place to continually assess your employees’ and your sys-

tem’s functionality. In EMS, we call this quality assurance and quality

improvement. Audit processes should be part of any EMS system

to ensure high performance and reliability on any call.

I strongly encourage you to research Admiral Rickover including

his speech to the U.S. Naval Postgraduate School in 1954. Because

of his responsibilities of managing and leading a high-risk system,

much can be learned from this man who enjoyed many successes

in his career.

AB O U T THE AU TH O R Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL) Fire Department. He is a well-known author and lecturer who has managed award-winning metropolitan fire-based EMS systems in St. Louis and Memphis. He has a total of 37 years of fire and EMS experience and has been a paramedic for over 35 years. Contact him at garyludwig.com.

Gary Ludwig is a featured speaker at EMS World Expo, Oct. 3–7, in New Orleans.

LUDWIG ON LEADERSHIP By Gary Ludwig, MS, EMT-P



This CE activity is approved by EMS World, an organization accredited by the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS), for 1 CEU upon successful completion of the post-test available at EMSWorldCE.com. Test costs $6.95. Questions? E-mail [email protected].

» Discuss the anatomy and physiology of depression and bipolar disorders

» Review assessment of symptoms associated with mood disorders

» Discuss treatment options for these patients

This article is republished from the EMS Reference, an online, peer-reviewed EMS journal. Read other evidence-based articles at emsreference.com.

AN EMS GUIDE TO By Robert J. Sullivan, BA, NREMT-P, & Shauna Sullivan, LCSW, LLC Your partner groans after you

are dispatched for a 25-year-old female who feels depressed. As you walk to the truck, he asks why someone who is depressed

needs an ambulance and what you are supposed to do for them. You think about a podcast you just listened to about how many EMS providers believe that psych calls are an abuse of the EMS system. You wonder if those findings would be different if more EMS providers understood how common mood disorders are, how biological chang-es affect mood and the impact therapeutic communication by EMS can have.

IntroductionDepression and bipolar disorder are catego-rized as mood disorders and are frequently associated with calls for EMS. People with depression experience profound sadness, guilt and loss of interest in activities, while people with bipolar disorder experience those symptoms along with periods of high energy, euphoria and irritability. Paramed-ics may be called for a primary complaint involving a mood disorder, or it may be a comorbid factor in another medical condi-tion. Mood disorders may also present with physical symptoms that may be difficult to differentiate from a medical problem.

A thorough understanding of depression and bipolar disorder is necessary for para-medics to differentiate medical from psychi-atric causes of presenting symptoms, to use therapeutic communication techniques for crisis mitigation and to determine whether a patient is competent to decide on their care. Some EMS services have gone further by implementing programs to improve crisis intervention, refer certain patients directly to mental health facilities instead of emer-gency departments, and conduct home visits to prevent the need for future 9-1-1 calls.

Anatomy and PhysiologyControl of mood is believed to take place in a circuit within the cerebrum. Comprising most of the brain mass, the cerebrum is responsible for judgment, decision-making and executing functioning. It contains five distinct regions: the cerebral cortex, corpus callosum, basal ganglia, hippocampus and amygdala.

The prefrontal cortex is located within the frontal lobe and is responsible for mood,

attention and immune functioning. The hippocampus helps regulate emotions and memory, and is one of the few areas that produces new neurons. The amygdala is also involved with the formation and recall of memories, and the expression of negative emotions.1 The hippocampus and amyg-dala are part of the limbic system, which processes emotional information, sets the level of arousal and is involved in motiva-tion. The limbic system can be described as the connection between the “thinking brain” and the “feeling and reacting brain.”2

The functions of each of these regions in the brain are controlled by approximately 100 billion neurons, and neurotransmit-ters are responsible for communication between them. An electrical impulse is first received at a neuron’s dendrite, which is an antenna-like extension. The impulse then travels down the axon and into the nerve ending, where the neuron is stimulated to release the neurotransmitter into the syn-apse, which is a tiny space between neu-rons. The neurotransmitter may then move across the synaptic space and stimulate the dendrites of another neuron by attaching to specialized receptor sites, be reabsorbed through a process known as reuptake, or be broken down by enzymes in the synapse. Neurotransmitters may stimulate a neuron to “fire,” and trigger an electrical impulse, or they may transmit an inhibitory message that stops impulses. Serotonin and norepi-nephrine are the neurotransmitters most strongly linked to mood, but dopamine and gamma-aminobutyric acid (GABA) recep-tors are as well.1,3

Hormones also play a role in mood. During times of stress, the adrenal glands release cortisol into the blood stream, which increases blood sugar, suppresses the immune system and aids the metabolism of fat and protein. High cortisol levels are use-ful in short-term “fight or flight” situations, however, over time they are associated with depression and anxiety.1 Estrogen and pro-gesterone are naturally occurring hormones that also affect mood. During pregnancy, levels of both hormones increase up to 50 times above normal, with a sudden drop below normal immediately after pregnancy.1 Between 80%–85% of women experience mood changes during the first four weeks after pregnancy. These symptoms of post-

partum depression (PPD) are often called the “baby blues.” Between 10%–30% of mothers continue to experience them in the following weeks.1,4 PPD is different than post-partum blues. Postpartum blues are normal and mild. PPD, which is more severe, is not normal. It is a form of clinical depression that typically occurs within four weeks after birth. It may last up to a year.1,4

PathophysiologyDepression has been linked to low levels of the neurotransmitters norepinephrine and serotonin. One theory is that the neu-rotransmitter reuptake mechanism may be too active, and these neurotransmitters are removed from the synapse before they can stimulate another neuron.1 Another theory states that these symptoms are caused by dis-ruptions in the circuit between the prefrontal cortex, hippocampus and amygdala, which are lined with serotonin receptors. Scans show lower levels of activity in these areas for people with depression.1,3 Yet another theory involves glutamatergic dysregulation.4

The cause of bipolar disorder is less understood. It has a strong genetic com-ponent. This is demonstrated through identical twins, who have a 40% chance of developing bipolar disorder when one twin is diagnosed, compared to 5%–10% of first-degree relatives and 1%–2.5% of the general population.1

One theory is that although depression is still caused by low levels of serotonin and norepinephrine, the manic episodes are caused by spikes in norepinephrine. Another theory is that irregularities in impulse transmission within neurons cause them to fire either too rapidly, which results in mania, or too slowly, which results in depression.1 If this is misdiagnosed as depression, some prescribed medications may trigger a manic episode by increasing levels of serotonin and norepinephrine.6

Although a genetic predisposition may be important in providing the biological com-

Photos by Prudy Pierson


dispatched, but they are not on scene yet. You are greeted outside of the residence by a man who says he called 9-1-1. He reports he is the patient’s coworker and that they are also dating. He explains the patient is being treated for depression, has not been feeling well over the past week and that he came to check on her when she did not show up at work. He reported the patient said she could not get out of bed this morning, that she is still in bed now, and that she does not want any help. He is concerned that she may want to harm herself, however, and called 9-1-1 because he did not know what else to do. He says there are no weapons in the residence, and no one has been drinking any alcohol or using drugs.

AssessmentThe following are the goals of a paramedic assessment for mood disorders:

» Identify safety threats; » Establish a rapport; » Rule out medical causes of symptoms; » Determine whether the patient has any

suicidal or homicidal thoughts, and

» Establish the patient’s decision-making capacity.

The safety assessment begins with the initial dispatch—for EMS providers, bystanders and the patient. Law enforce-ment should be sent along with EMS if any threat of violence is detected during the 9-1-1 call, and should enter the scene before EMS. Even if law enforcement is present, remember that safe situations can escalate into dangerous ones. Although few people with a mood disorder become violent, EMS providers need to be aware of the following few red flag behaviors:

» Increasing agitation; » Loud speech; » Threats to harm oneself or someone

else; » Clenched fists; » Pacing and » Threatening gestures.11

One consideration, however, is wheth-er the patient’s anger is concerning their situation or directed at caregivers. Yell-ing about a situation may be acceptable, because anger is a normal response to

potentially negative financial or social consequences associated with hospital-ization. A patient with this form of anger may respond to verbal de-escalation. On the other hand, anger or threatening state-ments directed toward caregivers should be taken seriously and are best managed by law enforcement.12

When possible, keep bystanders or family members a safe distance from an agitated patient, and position yourself between the patient and an escape route. Unless retreat is necessary, stay with the patient and attempt to assess them in the room in which they are found. Allowing them to go into a kitchen or bedroom is an opportunity for them to obtain a weapon.

The first few moments of a patient encounter often determine how smoothly the call will go, and it is essential to establish a rapport with the patient. Form a general impression about the patient’s appearance, general health, cleanliness and living con-ditions. If possible, position yourself at the patient’s eye level at a 45º angle, without encroaching on their personal space. Your

ponent of mood disorders, environmental factors can exacerbate or induce the onset of symptoms. Risk factors such as trauma, stress or intense conflict within families can increase the likelihood of development of a mental health disorder where genetic factors are already present.3,6 Changes in exposure to light and sleep patterns can affect serotonin and cortisol levels, and they may lead to depression. One form of depression is seasonal affective disorder, which causes a change in symptoms from season to season depending on climate and light exposure.

Signs and SymptomsMood changes are normal responses to life events and usually do not impair daily functioning. It is expected to feel sad after the death of a loved one, or to feel energetic after an accomplishment. A diagnosis of a mood disorder depends on the length and severity of symptoms and how much they interfere with daily activities.

Depression is characterized by feelings of sadness, lack of energy, low self-worth, guilt or loss of interest in activities. It may present with crying spells, a flat affect or angry outbursts. Some people who are depressed may lose their appetite or expe-rience insomnia, while others may overeat or sleep excessively. Physical pain—includ-ing headaches, indigestion, dizzy spells or generalized pain—is also common.1,3

Extreme cases of depression may have psychotic symptoms, which are a loss of contact with reality. These include delu-sions, which are ideas without a foundation, or hallucinations, which are the auditory, tactile or visual perception of things that are not actually present.

Another symptom of depression is catato-nia, which presents as an inability to move, purposeless motor activity, involuntary rep-etition of words or phrases, or posturing.1,3 Catatonia can be difficult, if not impossible, to differentiate from a neurologic condition in the emergency setting.

Bipolar disorder is characterized by fluc-tuations between periods of depression and manic episodes. Symptoms of the manic phase include feelings of euphoria, high energy and powerful emotions. There may be an inflated self-esteem or grandiosity, and the euphoria is often out of propor-

tion with life events. During an episode, a patient with bipolar disorder who is experi-encing a manic episode may report having racing thoughts and a decreased need for sleep.1,6 Also common is tangential think-ing, or rapid speech patterns about several unrelated topics.4 A patient experiencing a manic episode may also engage in reckless behavior or direct anger at people perceived as getting in the way of their ambitions. Delusions and hallucinations may occur in extreme forms of mania as well.1,6

With bipolar disorder, the episodes of depression tend to occur more frequently and last longer than manic ones. Some people experience rapid cycling, which is defined as four or more mood cycles in a year.1,6 Even with rapid cycling, the tran-sition occurs over days—not minutes or hours. Patients who present in one state are unlikely to transition to the other during the course of care with a paramedic. However, people with bipolar disorder may also have “mixed states” in which they have manic symptoms while feeling depressed.1,6 These mixed states account for 40% of inpatient admissions for bipolar disorder.1

On the way to the call you think about the stories you read on the Code Green Cam-paign’s website from EMS providers who live and work with mood disorders. You wonder if their partners knew how much some of those people were suffering sometimes and if it would change their attitude towards patients with those conditions.

EpidemiologyMajor depression is the leading cause of disability in people between ages 15 and 44 in the U.S., and by 2020 is estimated to be the second-leading cause of disability in the world.1,5 As many as two thirds of people with depression do not realize they have it, and nearly 20% of patients with untreated depression ultimately complete suicide.3

Approximately 8% of adults in the U.S. suffer from severe depression in a given year. About 5% suffer a less severe form, and around 19% of adults experience at least one episode of major depression in their life. It is twice as common among women, with 26% of women having at least one episode in their lives, compared with 12% of men.1,3 People of any age may suffer from depres-sion. The mean age of onset is 32, and it is

most common among people in their 40s.1,5

Depression is also prevalent among people with other medical problems and is associ-ated with a higher mortality rate than non-depressed patients.3 It is experienced by 50% of stroke patients, 30% of cancer patients, 20% of heart attack victims, and 18% of people with diabetes.1 Depressed patients are also less likely to adhere to treatment regimens for their chronic illnesses.

One meta-analysis of studies examining chronic illnesses and depression found that patients with depression were 1.76 times more likely to be noncompliant with their prescribed medication usage.7 Another meta-analysis of diabetic patients found a correlation between depression and non-adherence to treatment plans.8 Noncom-pliance with chronic illness management contributes to frequent and preventable EMS and emergency department usage, as well as high healthcare costs.9

EMS practitioners are not immune from depression. In 2009, the National Registry of EMTs included an optional validated survey to assess symptoms of depression, anxiety and stress for reregistering EMTs and para-medics. It found that 6.8% of reregistering EMS practitioners was depressed. Rates were higher among paramedics than EMTs, and among all practitioners who worked for a county or private EMS service, who worked for services with a moderate call volume, and who had more than 16 years of experience. This was the first study of its kind to address these issues in the U.S. and is an area for further research.10

For bipolar disorder, 4.7% of people suffer from some form of it during their lifetime.5 The prevalence among adults of bipolar I at any given time is 1%, 1.1% for bipolar II, and 2.4–4.7% for cyclothymic disorder.5 It can be diagnosed at any age after childhood and is most commonly diagnosed in late teens to early adulthood. Bipolar is diag-nosed equally among men and women even though women experience more depres-sion.1,5 The lifetime risk of a completed suicide attempt for patients with bipolar disorder is 17%.5 According to the National Mental Health Association, 80% of people with bipolar disorder may be misdiagnosed or not diagnosed at all.1

You arrive on scene at a well-kept subur-ban residence. Law enforcement has been

Diagnostic CriteriaThe American Psychiatric Association publishes a classification of mental disorders in the Diagnostic and Statistical Manual. Its fifth edition was published in 2013, and is referred to as the DSM-V. Diagnoses are based on an objective list of symptoms after evaluation by a mental health professional.

The DSM-V defines a major depressive disorder as five or more symptoms during a two-week period that cause significant distress or impairment. The following are those symptoms:

» Daily depressed mood most of the day; » Daily diminished interest or pleasure in almost all

activities for most of the day; » Significant weight loss or weight gain or daily increase

or decrease in appetite; » Daily insomnia or hypersomnia; » Daily psychomotor agitation or retardation; » Daily fatigue; » Daily feelings of worthlessness or hopelessness; » Recurrent thoughts of death or suicide; » A suicide attempt or plan for death by suicide; and » No history of a manic or hypomanic episode.1

Note: Visit the American Association of Suicidology’s Recommendations of Reporting on Suicide for more on the discussion of preferred terminology regarding suicide,

including the following terms used in this article: “death by suicide” and “suicide completion.”

The DSM-V uses the following diagnosis of bipolar dis-order in its definition of a manic episode:

A period of at least one week of abnormally and per-sistently elevated, expansive or irritable mood, and per-sistently increased activity or energy, for most of the day, nearly every day, causing significant problems.

Presence of at least one of the following symptoms: inflated self-esteem or grandiosity; increased talkative-ness, or pressure to keep talking; decreased need for sleep; flight of ideas or racing thoughts; distractibility; increase in goal-directed activity or psychomotor agita-tion; and excessive involvement in activities that have a high potential for painful consequences, such as over-spending, overeating or promiscuity.1

The DSM-V contains two types of bipolar disorder. Bipolar I disorder includes a history of a manic episode and symptoms of major depression. Bipolar II disorder also has a history of major depression, but with hypoman-ic episodes. Hypomania includes the same symptoms as mania, but the distinction is that they are less severe and do not cause significant impairment to daily function.1,6 Cyclothymic disorder, another diagnosis in the DSM-V, is one in which a person experiences numerous hypomanic symptoms and mild depressive symptoms.1


ception is intended to determine whether the patient is hallucinating. This is evident when the patient makes statements that do not match reality, or broadcasts their thoughts.5 Ask the patient if they hear or see things that others cannot hear or see. Patients having hallucinations may also stare at a focused spot in the distance, mutter under their breath or scratch their limbs.

A mental status exam reveals that she is oriented to person, place, and time, focuses on the person speaking to her, and answers questions clearly. She sits up in bed when you ask her, but appears sad, and says she has not eaten anything for two days. She also says she stopped taking her medication a week earlier because it made her nauseous, and that she did not feel that it was work-ing anyway. The patient denies feeling like she wants to harm herself or anyone else. She also says she does not want to go to the hospital because she is afraid of missing more work. You tell her you understand she does not feel like going to the hospital, but there are people there who can help her feel better, and people who care about her would worry if she does not go. After about 30 minutes, with some encouragement from her boyfriend, she agrees to go to the hos-pital. You ask if she would like to go on the stretcher or to walk to the ambulance, and she chooses to walk.

Your partner starts driving while you repeat vital signs, and her boyfriend fol-lows behind. When you finish taking her blood pressure, you ask again if she has ever thought about hurting herself. She then acknowledges that she has hoped that she would not wake up after falling asleep, and wondered if she had enough medication in her pill bottles to do that. She then says she did not want her boyfriend to know that, and hoped that does not mean she has to be admitted to the hospital. You explain that you don’t know whether she will be admitted or not, but you do have to report that to the ED staff when you arrive.

A suicide assessment is especially impor-tant when called for people with a mood disorder. Remember that asking a patient about suicide will not put thoughts in their head about it.4,11 Instead, it gives the patient an opening to talk about it, and is something paramedics should be comfortable speaking with patients about.

When possible, a suicide assessment is best done with bystanders outside of hear-ing distance, conducted either in a sepa-rate room or in the ambulance. In addition, open-ended questions should initially be used. Ask about the onset of their symp-toms, and if anything changed today. If the patient did not mention suicide dur-ing another part of the MSE, directly ask them about it. One script to use as a guide is “Some people in your situation feel like hurting themselves. Do you feel like that now?”11 Patients may deny suicidal intent, but also say they felt that way earlier that day or another recent time. This is also important to continue to explore in order to accurately assess safety. If patients do express a current desire to hurt themselves, use close-ended questions to determine whether they have a plan in mind and the means to carry out that plan.

The following generally indicate a more serious threat:

» Detail: The more detailed the suicide plan is, such as describing how they would use a weapon or the dosage of a medication they would take;

» Means: By having the means to carry out the plan, such as possessing a weapon or large quantity of medication, and

» Destructiveness: The more lethal the method is, such as using a firearm compared to taking pills.

The patient goes on to describe how she has had problems with depression since high school, but that it has never been this bad before. She sees a therapist and has tried three different medications with a psychiatrist, but she feels hopeless that her symptoms will never get better. You nod your head as she speaks, and say you are sorry she feels so badly. You offer to answer any questions she has about her care, and if there is anything you can do to help her feel better.

TreatmentWhen EMS is called for symptoms of a mood disorder, treatment should focus on maintaining patient safety, therapeutic communication, and relaying information to the receiving facility. Remember that to the patient, a mental health crisis is a true emergency they have little control over, and they deserve respect and compassion from the people who arrive to care for them. In

some cases, physical or chemical restraint may be required for agitation, or if it is determined that patients must be transport-ed against their will. Long-term treatment is managed by mental health professionals, including psychiatrists, psychologists, social workers and counselors, through medica-tions and therapy. Many communities have mobile crisis teams that visit mental health clients and can involuntarily commit them to a mental health facility if deemed nec-essary.

For paramedics, much of the therapeutic benefit for depressed and manic patients is with communication. Speak clearly and slowly, and avoid sounding sarcastic or judg-mental.12 Allowing the patient to talk allows them to process what is bothering them and you to reassess their mental state. Use eye contact, nod occasionally and paraphrase back what the patient tells you. This shows them you are listening empathetically. Some patients may not feel like speaking, and paramedics should not feel the need to fill silence during transport.

When verbal de-escalation or negotiation is necessary, one technique is to use “but” statements. Start by paraphrasing some-thing the patient told you, then say “but,” and direct them back to the goal of the con-tact. An example is “I understand that you are depressed and just want to stay home, but your family is very worried about you, and want you to get help at the hospital.”11

Agitated patients who do not respond to verbal de-escalation and who require physi-cal restraint may benefit from chemical sedation. Common sedatives administered by paramedics include benzodiazepines and antipsychotics. Benzodiazepines, which include diazepam (Valium), lorazepam (Ativan) and midazolam (Versed), work by stimulating GABA receptors to produce neuronal inhibition. These may be admin-istered intranasally, intramuscularly or intravenously. Respiratory depression and hypotension are two side effects that must be monitored after administration. Ket-amine is also administered by paramedics in some countries.13

Some agents more commonly adminis-tered in the hospital setting are clonazepam, olanzapine, and risperidone. Antipsychotics include haloperidol (Haldol), droperidol and ziprasidone (Geodon). These cause sedation

facial expression should convey that you are calm and nonjudgmental.4

Once you have established scene safety and a rapport with the patient, proceed with the same primary assessment you would for any medical complaint. Check for air-way patency, the effectiveness and work of breathing, and circulation by the presence and rate of a radial pulse and skin condition. Keep in mind that people with behavioral emergencies often have undiagnosed active medical problems.

If no problems are detected in the pri-mary survey, proceed with a mental status exam (MSE). This is a standard approach used by mental health professionals to objectively assess a patient’s state of mind. It also serves as an organized method for paramedics to detect a medical cause of the patient’s symptoms. Patients with depres-sion and bipolar disorder may present with

an altered level of consciousness that may be caused by a problem other than their mood disorder, such as a seizure, cerebrovascular accident (CVA), overdose, hypoglycemia or sepsis.5

Law enforcement arrives a short time later, and you enter the residence with the patient’s boyfriend. No safety threats are found as you scan the residence, and you have planned an egress route from the patient’s bedroom if the situation escalates. The patient is lying in bed, and appears upset that paramedics and police were called. She states she does not want any help and all she wants is to be left alone to sleep. You kneel down to eye level with the patient, introduce yourself and your partner, and ask her name. You explain you were called because someone cared about her and you are only here to help. You ask if she would mind if you ask her some questions and check her vital signs.

After ruling out a medical cause of the symptoms, the MSE provides objective information for caregivers to determine the most appropriate plan of action and to document justification of that action. This includes determining whether the patient has the mental capacity to consent to care or refuse to be transported to the hospital. Objective MSE findings should be discussed with online medical control and law enforcement to help make this decision.

Components of the MSE include assess-ing the level of consciousness, orientation, activity, speech, thought, memory, affect and mood, and perception. It can be remem-bered using the mnemonic COASTMAP, which stands for consciousness, orientation, activity, speech, thought, memory, affect/mood, and perception.5 Use open-ended questions while performing this exam, such as asking patients how they feel or why they think they feel bad. To assess conscious-ness, determine whether the patient is alert, confused, requires tactile stimulation for arousal or is unresponsive to pain. Note the patient’s ability to concentrate during your assessment. Observe whether they are easily distracted or can focus on a conversation. For orientation, ask the year, month and current location. Look not only for accuracy, but also how long it takes to answer.5

Activity is an examination of the patient’s behavior. Are they able to do what you ask, such as sit still in a chair? Do they pace around the room, or are they sitting still without moving at all? For speech, note the rate, volume and articulation. Is it fast or slow, loud or soft, garbled or slurred? To assess thought, listen to content of the patient speech. Does it make sense in the context of the situation, or is there a flight of ideas or delusion? To assess memory, tell the patient your name when you first introduce yourself, ask if they remember it later. Asking when and what they last ate is also useful to detect a medical cause of their mentation. Like orientation, observe accuracy and how long it takes the patient to answer.5

Affect and mood are objective findings about the patient’s body language. Note their posture and facial expressions, as well as statements they make. Do they appear euphoric or sad, and would it be considered appropriate for the situation? Assessing per-

Tips and Trick sEMS practitioners at all levels receive less training in managing psychological complaints than other medical problems, such as cardiac and respiratory problems. Many EMS practitioners may feel uncomfortable caring for patients with symptoms of mood disorders. Additional educational resources are available, such as local chapters of National Alliance of Mental Illness.

Give patients as many choices as possible, but do not offer one that is not available. If it has been determined that the patient has to go to the hospital for a safety reason, do not ask if they would like to go. However, if there is a choice of hospitals available, ask them which they would prefer to go to. The same principle applies to making promises. Do not make a promise that cannot be kept, such as promising the patient they will not be admitted while encouraging them to be transported. Promises like taking good care of the patient, keeping them safe, and helping them feel comfortable can be kept and should be delivered.

Some helpful comments might include stating why you are with them. » “I’m here to help you as much as I can.” » “I’m here to listen.” » “I’m here to see how we can help you feel better.”

Other tips on how to communicate with a patient with a suspected mood disorder include never telling a patient that you know how they feel; even practitioners who may have experienced symptoms of a mood disorder do not know exactly how another person feels at any given time. Also, do not tell a patient you can keep their information confidential from other responders because you will likely need to consult with law enforcement, mobile crisis or a receiving facility. During an assessment, ask questions preceded by a state-ment that can soften some of the direct questions about their safety, such as: “I am sure this is very hard to talk about, but please tell me…”

Additionally, telling a patient “everything will be OK” is counterproduc-tive because you do not know this to be true. If you feel the need to reassure someone in distress, one of the following statements would be better:

» “I will do everything in my power to help you.” » “Please let me know if I can answer any questions for you.”


by inhibiting dopamine receptors. One rare, but potential side effect of these medica-tions is that they may lengthen the QT interval and cause a ventricular dysrhyth-mia. Therefore, the patient should be placed on the cardiac monitor and have a 12-lead ECG obtained as soon as practical, and be monitored through the duration of contact.

One of the more difficult situations paramedics face is when a patient with a behavioral condition refuses to go to the hospital. Unless a patient is unable to make decisions believed to be in their own best interest, they have the right to refuse care. If, based on objective assessment findings, the patient is believed to be in imminent dan-ger to themselves or others, it is best to get early involvement of law enforcement, online medical control and/or mobile crisis coun-seling teams. They can determine whether an emergency petition is necessary, which

would allow the patient to be taken against their will for a psychiatric evaluation.11

It is important to accurately communi-cate findings to the staff at the receiving facility, both verbally and on the patient care report. The patient may share information in the ambulance that they may not repeat, either out of fear of a hospital admission or as a result of poor rapport with the staff. Documentation of a mental status exam should be objective, and include quotations of questions and answers. The hospital may use that information to determine whether the patient requires admission.11

Establishing trust and providing thera-peutic communication is an important skill for paramedics to use with psychiat-ric patients. However, paramedics are not therapists. Attempting to provide therapy is outside their scope of practice and should be done by mental health professionals.11

Active listening is helpful, but providing advice about managing their symptoms can cause harm.

For long-term care, a patient might seek treatment from one of several different cli-nicians. A psychiatrist is a medical doc-tor who has also had specialized training in mental health disorders and the neu-rophysiology of the brain. Psychiatrists typically see individuals for medication evaluation and management and do not do therapy. Appointments are of a shorter variety and focus on finding the appropri-ate psychotropic medication to treat the symptoms of the disorder. Since there is no permanent cure for mental illness, physicians must focus on finding the best medication with the fewest side effects to help the patient effectively live with their disease. In addition to medication man-agement, psychiatrists are also concerned

with a patient’s physical concerns, such as diet, exercise and maintaining a healthy lifestyle. They may monitor vital signs or order blood work to ensure their patients are physically metabolizing medications as expected.

Antidepressants aim to block the reup-take process in the synapses, enabling nor-epinephrine or serotonin to stay in synapse longer and bind to a postsynaptic neuron. The most common medications used today are the selective serotonin reuptake inhibi-tors (SSRIs), including fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and escitalopram (Lexapro). These medications are popular because they have fewer side

effects than other medications and make overdose difficult.1,2 Velafaxine (Effexor), desvenlafaxine (Pristiq) and duloxetine (Cymbalta) selectively block the reuptake of serotonin and norepinephrine. Wellbutrin (bupropion) acts on serotonin, norepineph-rine and dopamine receptors.3

Older medications include the monamine oxidase inhibitors (MAOIs), which inhibit the enzyme that breaks down norepineph-rine. These medications include phenelzine (Nardil) and tranylcypromine (Parnate). They are less commonly prescribed because of risk of high blood pressure, and they come with dietary restrictions. Tricyclic antide-pressants also block the neurotransmitter

reuptake process but have a higher risk of overdoses than other medications.1

A non-pharmacologic treatment for depression is light therapy. Exposure to bright light at certain periods of the day is believed to suppress the release of melato-nin, which can help both seasonal affective disorder and non-seasonal depression.14

Treatment of bipolar disorder includes a class of medications known as mood stabi-lizers. The most common mood stabilizer and first-line treatment is lithium. Other mood stabilizing medications are anticon-vulsants, which are the same medications used for seizures. These include carbam-azepine (Tegretol), valproate (Depakote)

A suicide assessment should be done on any patient who complains of feeling depressed. This is best done when the patient is away from family members or bystanders.

Community ParamedicsSome EMS services have adopted additional crisis inter-vention training to manage patients with psychiatric condi-tions. These include advanced practice paramedics who direct patients to mental health facilities, and community paramedics who visit patients with mental illnesses to pre-vent readmission.

Advanced practice paramedics (APPs) with Wake County (NC) EMS developed a program to direct patients with a psychiatric complaint directly to a mental health-care facility instead of an emergency department. Their APP academy included advanced clinical decision-mak-ing, pharmacology review, epidemiology of mental health and substance abuse, and the NAMI CIT course. Wake County APPs are automatically dispatched along with an ambulance to all incidents for mental health or substance abuse complaints. Using a screening checklist to rule out a medical cause of psychiatric symptoms, patients who are not agitated or combative can be directed to one of their partner mental health facilities. The patient can be trans-ported to the facility by EMS or law enforcement, and the APP delivers a face-to-face report with staff members at the receiving facility.17

Wake County APPs successfully diverted 940 mental health or substance abuse patients between July 2010 and December 2013.3 This significantly increased the amount of appropriate care psychiatric patients received and reduced emergency department (ED) wait times for patients with other complaints. The average ED stay for a mental health patient is 14 hours before they are admitted to state mental health facility or referred to their primary psychiatric provider. In contrast, the average initial evalu-ation and treatment time for patients with chest pain is three hours. Therefore, more than four chest pain patients could be seen in the room occupied by one mental health patient.18

Another program that provides advanced ALS care is the St. Paul, MN-based Allina Health community para-

medic (CP) program. In this hospital-based program, plain-clothed CPs conduct home visits to people recently discharged from a psychiatric facility. Approximately 25% of mental health patients discharged from Allina Health return within one month, mostly due to barriers to follow-up care. Sixteen plain-clothed paramedics provide this service in unmarked Ford Escapes to reduce the stigma associated with frequent ambulance and police respons-es for people in a mental health crisis who pose no safety threat. Allina CPs assess patient compliance with treat-ment plans and transport patients to appointments—all with the goal of preventing a future 9-1-1 call or hospital admission for a crisis. Because of a shortage of beds at mental health facilities in the region, the CP program saves ambulances unit hours that can be used for other medical problems.18

In Fort Worth, TX, MedStar Mobile Healthcare’s com-munity paramedic program identified depression and its related substance abuse as one cause of frequent 9-1-1 calls for a small number of patients for exacerbations of chronic conditions. These psychosocial problems cannot be adequately managed in the emergency department, and patients are often admitted or observed only because of concerns about the patient’s ability to care for themselves. Patients who become enrolled in MedStar’s mobile health paramedic program receive an initial 1.5–2 hour assess-ment from a mobile health paramedic, which includes examining access and need for mental health services.

Mobile health paramedics develop a plan to get patients identified resources, assess compliance with an agreed-on treatment plan, and stay in contact with pri-mary care and mental health providers. From July 2009 to November 2013, 9-1-1 usage among enrollees dropped 86% after graduation from the program. This translated to an estimated average of more than $23,000 saved per enrollee in ambulance and ED charges, and an estimated 14,000 ED bed hours freed.9


and lamotrigine (Lamictal). The exact mechanism of action of these medications is unclear. One theory is that they work on impulse transition within the neuron by stimulating neuroprotective protein, and may also affect the sodium/potassium ion transmission within the neuron.1,5,15

Another class of medications used to treat bipolar disorder is atypical antipsy-chotics. These were initially developed as a newer class of medications to treat schizo-phrenia, and include olanzapine (Zyprexa), quetiapine (Seroquel) and aripiprazole (Abilify). These medications work on cer-tain dopamine and serotonin receptors.1

Patients may see a psychiatrist alone or in conjunction with a therapist for more involved treatment regarding their mood disorder. Often, patients will seek out therapy at the recommendation of their psychiatrist, or may search independently for a therapist. Therapists can come from a variety of backgrounds and education levels, and are typically divided into two primary groups: a doctorate-level and master’s-level. Doctorate-level therapists are psychologists, who hold a PhD or a PsyD in clinical psychology. There are a number of master’s-level therapists with different educational approaches, including clinical social workers, professional counselors of mental health and pastoral counselors. Typ-ical suffixes for master’s degree therapists may be “LCSW” for licensed clinical social workers, “LPCMH” for licensed professional counselors of mental health or “MA” for Master of Arts. These clinicians do not pre-scribe medications, but often communicate with a patient’s psychiatrist to coordinate treatment goals.

In addition to long-term care, mobile cri-sis units are available in many communities for life-threatening mental health incidents. In cases of someone feeling suicidal or hom-icidal, mobile crisis units are dispatched either by an individual, police department or paramedics to assess a patient for safe-ty. Units are comprised of trained mental health workers who are familiar with treat-ment options in their area and how to assess a patient’s safety. In certain cases, mental health workers may seem less intimidating to a patient than police officers or EMS providers, and they can work in conjunc-tion with officers to determine the next

treatment option. Depending on services available in a given area, workers may rec-ommend involuntary inpatient treatment, voluntary inpatient treatment or follow-up with such outpatient providers as a thera-pist, psychiatrist or partial hospitalization programs.

Some law enforcement and EMS agen-cies have adopted mental health crisis inter-vention training. The National Alliance on Mental Illness (NAMI) Crisis Intervention Team program is a 40-hour course that includes identifying specific mental ill-nesses, learning de-escalation techniques and getting clinical time with mobile crisis units. It was originally developed for law enforcement to better respond to people in mental health crisis and reduce incar-ceration rates, and has been used by EMS services to better manage these situations.16

After you report what the patient told you to the ED staff, wish her well and document her statements in your PCR, your partner tells you he does not understand why an ambu-lance had to be tied up for that patient. You reply that the patient felt comfortable telling you things she did not feel comfortable telling anyone else, and that her outcome may have been much different had you not been called. You also tell him people call 9-1-1 when they don’t know what to do, that pain from mental illness is a real as pain from other medical conditions, and it was in the patient’s best interest to be evaluated in the emergency department.

You go on to explain that behavioral emer-gencies may be an area for paramedics to specialize in. With some additional educa-tion and clinical rotations, perhaps para-medics could medically screen patients with psychiatric complaints and direct them to resources that are more appropriate to care for them than an emergency department.

ConclusionDepression and bipolar disorder are clas-sified as mood disorders, which have bio-logical causes that may be exacerbated by environmental changes. Together, they are a frequent reason for calls to EMS, both as a mental health crisis and as a contribut-ing factor in medical complaints. EMS care focuses on assessing safety, determining the patient’s decision-making capacity and providing therapeutic communication. A

thorough understanding of mood disorders is needed to effectively perform these tasks and to direct patients to the most appropri-ate facility.

RE FE RE N CE S

1. Comer RJ. Abnormal Psychology. 8th ed. New York: Worth; 2014. p. 223–283.2. Swenson R. Review of Clinical and Functional Neuroscience; 2006. Dartmouth Medical School. dartmouth.edu/~rswenson/NeuroSci/chapter_9.html.3. Halverson JL, et al. Depression. Mediscape, c1994–2014. emedicine.medscape.com/article/286759-overview.4. Frye MA, et al. Increased Anterior Cingulate/Medial Prefrontal Cortical Glutamate and Creatine in Bipolar Depression. Neuropsychopharmacology, 2007 Dec;32(12):2490–9.5. Stratford C. Behavioral emergencies. In: Pollak AN, Elling B, Smith M, editors. Nancy Caroline’s Emergency Care in the Streets. 7th ed. Sudbury: Jones & Bartlett. p. 1369–97.6. Soref S, McInnes LA. Bipolar Affective Disorder. Medscape, c1994-2014. emedicine.medscape.com/article/286342-overview.7. Grenard JL, et al. Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis. Journal of General Internal Medicine, 2011;26(10):1175–82.8. Gonzalez JS, et al. Depression and diabetes treatment nonadherence a meta-analysis. Diabetes Care, 2008;31(12):2398–2403.9. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. Trained paramedics provide ongoing support to frequent 911 callers, reducing use of ambulance and emergency department services. Innovations exchange. 2014 January 29.10. Bentley MA, MacCrawford J, Wilkins JR, Fernandez AR, Studnek JR. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care, 2013;17:330–338.11. Polk DA, Mitchell JT. Prehospital Behavioral Emergencies and Crisis Response. Sudbury, MA: Jones & Bartlett, 2009.12. Teitsort K. Verbal Skills. In: EMS Safety: Taking Safety to the Streets Course Manual. National Association of Emergency Medical Technicians, 2011. p. 109–110.13. Scheppke K, et al. Prehospital use of IM Ketamine for sedation of violent and agitated patients. Western Journal of Emergency Medicine; 15(7):736–741.14. Golden R, et al. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Am J Psychiatry, 2005; 162:656–662.15. Frye MA. Bipolar Disorder — A Focus on Depression. N Engl J Med, 2011;364:51–9.16. National Alliance on Mental Illness. Crisis intervention teams. nami.org/template.cfm?section=CIT2.17. Guillaume G, Linder GE, Lyons M, McDougall L, Nayman BD. Taking substance abuse and mental health out of the emergency department. EMS World; January 6, 2014.18. Serres C. For mental health patients, an unmarked ride to psychiatric care. Star-Tribune, July 16, 2014.

AB O U T THE AU TH O RS Robert J. Sullivan, BA, NREMT-P, is a paramedic with New Castle County (DE) EMS and teaches with the paramedic program at Delaware Technical and Community College. Contact him via e-mail at [email protected].

Shauna Sullivan, LCSW, LLC, is a licensed clinical social worker with more than 10 years experience in the field. An alumna of Bryn Mawr College and the University of Delaware, she has experience in outpatient, intensive outpatient, and inpatient facilities for those challenged by mental illness. Presently, she operates her own private practice in Wilmington, DE, where she sees individuals and families for outpatient treatment.


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Joseph Lieberman- Former Chairman of the Senate Committee on Homeland Security

THE MIDLIFE MEDIC By Tracey Loscar, NRP, FP-C


The fact that you’ve been

doing this job for 20

years means you can read

a schedule, not an EKG.

Your Mileage May Var yBeware of judging ability by age

I am not 50 years old, but I can see it from here.

Despite my aching joints and the ridiculous amount

of silver in my hair, I am not ashamed of my years

and get a kick when my age and/or experience takes

someone by surprise. Including all of my experience I

have been in EMS for 30 years, most of that in a high-

volume system in Newark, NJ. I have a round, relatively

unlined Irish face and a talented colorist on retainer. In

my off time I avoid all things uniform and can blend into

the crowd at retail outlets or flea markets, depending on

if I’m wearing the dressy yoga pants or not. It is easy to

assume I am nobody of significance or experience. That

is just fine with me.

EMS, like many other physical jobs, is considered a

young person’s field. It is a tiring job that is physically

and emotionally exhausting. Providers enter the field in

far better shape than they leave it. Years of shift work,

too little sleep, too much garbage food and spikes in

adrenaline are a damaging combination. It is possible to

counteract that by keeping in shape, but age is the great

equalizer. We all erode, just at different rates.

People get into this field for a number of reasons.

What happens when someone chooses EMS as a second

career, or comes to it later in life? The same thing that

happens to younger people—they go through the same

training, frustrations and successes anyone else does.

They may be starting their day with Motrin instead of

orange juice, but they still get out the door. By the time

they get to work they look just like you do, only older.

With age comes wisdom, right?

Not quite. With age comes arthritis, but it does not

offer a natural increase in critical thinking skills or the

ability to perform prehospital medicine in a high-pres-

sure environment.

Unfortunately because we often attribute experience

to age, it is easy to overestimate the abilities of older pro-

viders and their patient contact time. We believe them

to be stronger or more capable practitioners and expect

them to perform at a standard above that of a novice

provider. We assume they know more or have done more

than they have, so we do not pressure them to learn or

practice more.

Age makes a good force field. Generally the older you

get, the easier it is to deflect assessments of your abili-

ties. I had a terrible time getting evaluated back East. I

would stand on the other side of a table from a young

instructor and they would say, “You know this already.

What could I possibly show you?” To be fair, in all likeli-

hood I had taught them at some point so I can under-

stand this.

When I took a position in Alaska earlier this year, I had a

clean slate. Absolutely nobody knew me when I started.

Although I had the mixed blessing of the fact that Alaska

is a lot like Madagascar, it is isolated and cut off from the

lower 48 so my background meant nothing.

In uniform I am no longer camouflaged. That singe of

silver in my hair and the lines around my eyes say that

maybe I’ve been around awhile. It means I have age; it

does not mean I have experience. The fact that you’ve

been doing this job for 20 years means you can read a

schedule, not an EKG. A good clinician should be up to

date and always refining their process. I learn so much

from the younger medics every day. The curriculum

today challenges me to revisit concepts and strate-

gies that once provided the foundation of my practice.

I spend a fair amount of time secretly Googling things

they show me, peering down at the screen through my

bifocals and hoping I can keep up with them.

The older provider brings maturity. They have a frame

of reference and perspective that can be invaluable in

facilitating the care of people in a broader generational

range. We get their jokes, and can support a valuable

argument when it comes to deciding just what qualifies

as “classic rock.” What we need from younger providers

is recognition that we have a lot to learn about this field

too and not to assume that because we creak when we

get out of the truck we know the answers to all ques-

tions. (Unless that question is about classic rock.)

People are surprised by my experience because I do

not look my age. I can be equally surprised by your lack of

experience; do not let me assume something when you

need my help. Communication is the way to make sure

everyone, including the patient, gets the most benefit

out of our combined years of experience, EMS or oth-

erwise.

AB O U T THE AU TH O R Tracey Loscar, NRP, FP-C, is a battalion chief for Matanuska-

Susitna (Mat-Su) Borough EMS in Wasilla, AK. Her adventures started on the East Coast, where she spent the last 27 years serving as a paramedic, educator and supervisor in Newark, NJ. She is also a member of the EMS World editorial advisory board. Contact her at [email protected] or www.taloscar.com.

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