The EMS Contrarian by Bryan E. Bledsoe

Danger at the Door

I am a proponent of EMS personnel having a more independent practice. The days of calling “Rampart Hospital” for an order of “D5W TKO” is a thing of the past. I truly feel that most of our educational programs are strong enough to support independent decision-making by EMTs and paramedics. But it is important to remember that independent decision-making also requires one to take responsibility for their decision and actions. This is somewhat of a new concept for EMS personnel.

One area where independent decision-making has been delegated to EMS personnel is selective spinal motion restriction (spinal immobilization). There is an excellent body of research that shows that the application of an established protocol allows EMS personnel to accurately and safely determine which patients should be immobilized and which should not. We have added it to our textbooks and many EMS systems have adopted it.

Spinal immobilization is uncomfortable and can cause complications in certain patients. Thus, like any other skill or procedure, it should be used when the patient stands to benefit from it. That is, when the patient has the possibility of a spinal injury. Certainly, with spinal injuries, we want to be extremely cautious and should have a high index of suspicion. Likewise, we don’t want to subject a patient to unnecessary discomfort and pain.

Unfortunately, a few trauma centers are reporting an increasing number of patients with spinal injuries who were not immobilized by EMS. At one hospital (on the east coast), 13.5 percent of patients with a documented spinal injury were not immobilized in the prehospital setting. The trauma outreach coordinator, an experienced paramedic, reviewed each case and found that each patient had met the criteria for spinal immobilization in the prehospital setting. That is a scary figure. Although it is just one hospital in one state, I have heard increasing talk amongst EMS medical directors about their concerns with the application of spinal immobilization.

Now, let’s look at this a little more closely. In the system where 13.5 percent of patients with spinal injury were not immobilized, a policy was in place to allow EMS personnel to determine who should be immobilized and who should not. The premise is that all patients should be immobilized unless they meet the criteria to bypass immobilization. The protocol requires that EMS personnel complete a structured, standardized exam (e.g. altered LOC, spinal pain or tenderness, neuro deficit, distracting injury). If the patient meets any of the established criteria, they must be immobilized.

So in 13.5 percent of the cases, EMS personnel performed an exam and came to the conclusion that immobilization was not necessary. Thus, from a negligence standpoint, this was an act of commission and not an act of omission. A jury would probably look more unfavorably on an act of commission. In reality, what this tells me is that some EMS personnel are NOT properly applying the protocol or applying it selectively. The protocol only works if applied in a standardized fashion—the same, each time and objectively—to ALL trauma patients.

EMS personnel want more autonomy, but autonomy requires integrity. Integrity is what you do when nobody is looking. Medicine requires an extremely high degree of integrity; shortcuts in medicine can harm people. In emergency medicine, we assume a patient has a severe injury until proven otherwise. It is the only safe way to approach things in a short period of time. This same adage holds true in EMS.

Quality monitoring in EMS should detect issues such as this — this is how the trauma system detailed above discovered the 13.5 percent miss rate — but quality monitoring must be applied uniformly and EMS personnel must be given the results on a regular and constructive basis. Personnel who are taking short cuts and making clinical assumptions should be counseled. This spinal immobilization trend may well turn out to be like the trend we saw in the late 1990s with unrecognized esophageal intubations. It cannot be tolerated.

There are many of us working to improve EMS. More pay and more independence are needed, but these come with the associated responsibilities. It is frustrating in that every time we make some progress, EMS finds a way to shoot itself in the foot and set things back. Let me close with this: Every time you are using a selective immobilization protocol, assume that the patient is a member of your immediate family. Apply the protocol systematically and uniformly. If in doubt, immobilize. Please, let’s not take another step backwards.

" src="http://www.ems1.com/data/img/btn_go.gif" align="absmiddle" border="0" height="16" width="16"> Related Resource: Spinal Assessment Protocol — Maine EMS

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Bryan E. Bledsoe, DO, FACEP, EMT-P is an emergency physician, paramedic and EMS educator. Dr. Bledsoe is the principal author of the Brady paramedic textbooks and others. He has more than 20 years publishing experience and has more than 900,000 books in print and has written more than 400 articles. He is a prolific writer, popular lecturer, and EMS researcher. Dr. Bledsoe is currently developing a distributive educational program for initial EMS education through the University of Nevada Las Vegas and online continuing education through Paramedic.com. Dr. Bledsoe maintains residences in Midlothian, Texas and Las Vegas, Nev. To contact Dr. Bledsoe, email bbledsoe@earthlink.net.

Benefits outweigh risks for air medical crews

By Robert Mitchum and Judith Graham
Chicago Tribune

AP Photo/Paul Beaty A Dupage County Emergency Management worker is comforted near the wreckage of a helicopter crash in Aurora, Ill. Four people, including a 13-month-old girl, were killed when a medical evacuation helicopter crashed overnight in the Chicago suburb of Aurora, authorities said early Thursday.

AURORA, Ill. — For medical professionals who climb on board helicopters hundreds of times a year, the job can mean dark, urgent flights through uncertain landscapes, emergency landings in cow pastures and medical equipment bouncing to and fro because of choppy winds.

But air medical transport also grants its workers the rush of flying above the world and the indescribable feeling of saving the lives of people who might not otherwise have been reached in time.

That is what has kept Mary Jo Dunne, 53, working as a flight nurse for 23 years on more than 2,000 flights with the University of Chicago Aeromedical Network, even as she hears all too frequently of medical helicopter crashes like the one that killed four people in Aurora.

"That will be on my mind when I get in the helicopter because of the loss of people, but I don't think we ever project that as being us," Dunne said. "For a very long time, my thinking has been clear that this isn't an inherently dangerous job. The benefit we're providing the patients should outweigh the risks."

Dunne and other air medical workers said Thursday that the latest accident, which follows a dozen other U.S. crashes in the last year, rattled them emotionally but did not shake their resolve to continue offering a unique and essential service.

"The focus is on the patient. I don't even realize what's going on around me," said Amanda Bostjancic, 28, a pediatric nurse for the intensive-care unit at Advocate Hope Children's Hospital in Oak Lawn.

Dangerous situations do arise, but Dunne said she puts absolute trust in her pilots. When thick ice on a helicopter's windshield forced an emergency landing several years ago, "the pilot had us on the ground before we realized what was happening," she said.

That wasn't the last challenge. "We had a patient on board, so I had to slog through a field full of cows to get to a phone and call a ground ambulance," Dunne said.

Paramedics, physicians and nurses who fly on air ambulances in the Chicago area cited several reasons for their career choice: the challenge of treating critical patients in an extreme environment, the unpredictability of each day's work, the independence of working closely with a small team.

"It's definitely a kind of adrenaline rush," said Cindy Rahilly, clinical operations assistant for the pediatric neonatal transport team at Hope Children's Hospital, who did air transports for about two years. "You're picking up a very critical patient. And because the doctor isn't with you, you have a lot of autonomy."

Dania Lees, 32, said she was obsessed with flying at a young age and got hooked on air medical transport from her first fly-along as a medical student at the University of Chicago.

"The minute I got up there, I said, 'This is what I want to do,'" said Lees, now a physician at Loyola University Medical Center in Maywood. "Not only the thrill of being able to fly, but to go and take care of a patient and fly them back to where you're confident they'll get the care they're going to need."

Dunne said the daily joy of seeing the world from a vantage point few experience is why she still works the 24-hour shifts the job demands even after two decades in the business.

"There isn't a minute that goes by that I don't enjoy flying," Dunne said. "The sunrises and sunsets. The cityscape, the farmlands in snow and moonlight. ... It's breathtaking and beautiful. The theater in which we practice is so beautiful it's beyond belief."

Copyright © 2008 LexisNexis, a division of Reed Elsevier Inc. All rights reserved.

What speed is safe on emergency runs?

What speed is safe on emergency runs?

June 17, 2008
By Dana Wilson
The Columbus Dispatch
Copyright 2008 The Columbus Dispatch

DELAWARE, Ohio — George Haggard was waiting for his wife to arrive home so they could go out to dinner when he heard the sirens blaring along Liberty Road.

He was shocked when, instead of her Dodge Caravan, an ambulance stopped at the end of his driveway along Carriage Road, near Powell. The medics told him Dorothy, 67, had been in a car crash.

"They said, 'Your wife is on a backboard in the back,' " Mr. Haggard, 70, recalled.

Her injuries mostly were minor, so he followed the ambulance to the hospital. Later, his wife described to him how her vehicle was hit by a deputy sheriff's cruiser.

It was just before 6 p.m. on June 5, and Mrs. Haggard was driving south on Liberty Road when she heard emergency sirens. She pulled off to the right berm. Heading north on the same road, Delaware County Deputy Charles Gannon Jr. lost control of his cruiser, according to the State Highway Patrol.

The cruiser went off the road, then sideswiped a Liberty Township ambulance stopped in traffic. The cruiser veered off the road again, then struck Mrs. Haggard's van, pushing it into a GMC Sierra also along the berm.

A fifth car that veered off the road to avoid the cruiser hit a tree instead.

Gannon, 33, later told troopers that he was en route to an emergency call and estimated he was traveling between 50 and 70 mph. The posted speed limit on Liberty Road is 45 mph.

The State Highway Patrol cited Gannon for operating a vehicle without reasonable control, a misdemeanor. His driving privileges at work have been suspended pending an internal review, Sheriff Walter L. Davis said.

"We'll look at everything," Davis said. "We understand that we have to be responsible. We understand that we have to, first and foremost, use good common sense and good judgment."

The crash, Gannon's second on-duty wreck, raises the question of how fast is too fast for an emergency vehicle.

The patrol says that depends on a number of factors, including the nature of the call, traffic, weather and time of day.

"He was cited for the crash, so they believe that there was some type of negligence, but it's a tricky call," State Highway Patrol Sgt. D.J. Smith said. "There is no, per se, 'You can only go this fast.'

"Firetrucks and medics cannot go 10 miles above the posted speed limit and must stop at red lights and stop signs, Liberty Township Fire Chief John Bernans said.

He said first-responders must evaluate every call and practice common sense.

"Are you running 90 miles an hour on a broken ankle versus a heart attack?"

Gannon said he was responding to a report of a suicidal person on June 5.

Mrs. Haggard was badly bruised in the crash and suffered torn rib cartilage. Drivers or passengers in two other vehicles suffered minor injuries.

"What he did is put my wife's life in jeopardy by a poor decision," Mr. Haggard said of Gannon. "If you're going to save a life, you don't want to endanger other people, too."

Cold Weather Emergency

Cold Weather Emergency

By Dana Sterner, RN

With winter setting in, having firsthand knowledge of cold weather emergencies like frostbite is a necessary triage skill for emergent care nurses.
Frostbite occurs when skin temperature drops below freezing, causing ice crystals to form at the cellular level. Frostbite can occur quickly or take as long as several hours.

Certain predispositions can make individuals completely unaware of its occurrence, including dangerously cold situations or prolonged cold exposure; heat transfer by a chemical such as gasoline or thru a thermal conductor such as metal; constrictive boots, gloves or head gear; immobility; vasoconstrictive medications or drug intoxification.

Four Degrees of Injury

Frostbite is categorized according to degree or depth of tissue damage.1
First-degree frostbite presents with an erythema appearing skin. Patients complain of a stinging or burning sensation but are able to move appendages such as fingers and toes.
No tissue damage has occurred at this stage. It is considered superficial. Skin may feel stiff to the touch because ice crystal formation has started, but the tissue underneath is still warm and soft.

Second-degree frostbite may be erythemic, gray, white, bluish white or even yellowish in color. The appendages are edematous, extremely tender to touch, difficult to move and may have superficial blebs. Patients have described a feeling of pins and needles sensation. The tissue will feel hard and frozen. Tissue damage has begun and will continue if left exposed and untreated.

Third-degree frostbite appears waxy, white, blotchy or blue as if mottled. Edema is present along with hemorrhagic vesicles. Patient will complain of a numbness followed by a burning throbbing or shooting pain. As skin temperature continues to drop plasma leaks out from the blood vessels into the surrounding tissue causing ice crystals to form outside the cells. The tissue will feel hard and has been damaged. Appendages are difficult to move. Treatment is necessary to prevent further deeper tissue damage.

Fourth-degree frostbite consists of damage to the subcuticular, muscular and osseous tissues. The skin appears dry, blue, black, or rubbery. There may be little or no swelling with complaints of a deep aching joint pain. Obvious damage has occurred at the deepest level and tissue is unrecoverable and the area may appear deformed.1,2

Treatment Options
There are several different treatment options for the patient presenting with frostbite.

First, address medical conditions such as hypothermia and airway management. At the same time, remove the patient from cold environments and prevent partial thawing and refreezing of their skin.

Avoid friction or massage such as rubbing as it will exacerbate damage to the patient’s skin. Carefully remove any wet clothing. Remove rings, watches or anything that is constricting to affected areas.

Frozen tissue should be thawed by immersion in warm, circulating water 37-42° C. Avoid hot water. If no thermometer is available, use water that is warm to the touch, but never hot.

Hydrotherapy should continue after initial thawing of the skin. The frequency and length of time will depend on the extensiveness of damage. Do not use direct dry heat, such as a hair dryer or electric blanket. Direct heat can burn the tissue that has already been damage.

Administer analgesics and encourage patient to gently move parts. Some patients may experience severe pain with reperfusion of tissue and may need parenteral narcotics.

Appendages
Loosely wrap a warm moist towel around frostbitten appendages, such as the ears or nose.

Movement should be encouraged to prevent venous stasis but no weight bearing should be allowed until swelling is resolved.

When possible, keep appendages elevated to reduce swelling. Place a soft cloth between affect appendages to absorb moisture and prevent sticking or rubbing.

There is some controversy over aspirating clear vesicles. If broken, debride the affect area and dress with sterile gauze and ointment. If left intact, the fluid will usually reabsorb in a few days. Follow your facilities policy and procedures concerning this.

Leave hemorrhagic vesicles intact to prevent infection. Some swelling and color change will occur during rewarming. Reassure patient this is normal.1-3

Additional Measures

Tetanus toxoid should be administered if a booster has not been given within the last 5 years. Tetanus immune globulin is recommended for those greater than 10 years since their last booster.2

Some sources recommend an antibiotic if skin is edematous and blistering suggesting edema makes skin more susceptible to gram positive organisms.2 Other sources suggest antibiotic use only if there is clear evidence of infection. Patients who are considered immuno-compromised will most likely be ordered antibiotic prophylaxis.1

Assessing tissue after rewarming is important. Monitor for tissue compartment swelling, infection and continued pain. Decisions regarding amputation should be deferred up to several weeks unless infection has developed.1 Doppler studies and angiography preformed at 1-2 weeks will help assess the vascular status and any extensive damage.2

References

1. Kasper, D., et al. (Eds.). (2005). Harrison’s Principals of Internal Medicine. (16th Ed) Hypothermia and Frostbite, (pp123-125). USA: McGraw Hill Professional Medical Publishing Division.

2. Reamy, B.V. (1998, Jan.-Feb.). Frostbite: review and current concepts. Journal of the American Board of Family Practice, 11(1), 34-40. Retrieved Oct. 16, 2006 from the World Wide Web: URL no longer available. 3. National Agriculture Safety Database. (2004, March). Cold weather exposure. Retrieved Oct. 9, 2006 from the World Wide Web: http://www.cdc.gov/nasd/docs/d001601-d001700/d001677/d001677.html

Dana Sterner is a registered nurse and freelance writer from Boonsboro, MD.