What Did You Say? A Humorous Look at Treating Deaf Patients

Steve Berry | From the January 2008 Issue | Monday, May 20, 2013

My nervous partner Eric loudly and with exaggeration asked the patient, “CAN. YOU. READ. MY. LIPS?”

The Deaf patient replied, “No. I. CAN'T. READ. YOUR. LIPS.”  The humor was lost on Eric as he relayed the patient’s limitations to me.

“Really?" I melodramatically replied. “I thought all Deaf inhabitants could visually convert external orifice configurations into meaningful linguistic interpretation.” The patient and I exchanged a brief grin.

“Now what are we going to do?” Eric was too nervous to notice my admiration for the patient’s cunning intellect. “I don’t know sign language,” he whined.

“Sure you do,” I deadpanned. “Show him your middle finger and see what happens.”

“Hey, I’m serious!” Eric blurted.

“How do you even know he uses sign language to communicate?” I questioned.

“Well, duh,” he asserted while confidently turning toward the patient with an affirming thumbs-up gesture. The patient returned the signal, mimicking my partner’s excessive body language and facial expressions.

Giving a satirical wink to the patient, I told Eric, “With pen and paper, ask the patient what method he would prefer to use when communicating with him.” With a deadpan expression the patient quickly jotted down one word and handed it back to Eric. “Brail.”

Poor Eric. He was a part-time newly licensed EMT who was not privy to the fact that I had once been a teacher for the Deaf and hard of hearing (D&HH) before I was naively drawn to EMS. Not that I volunteered that information to Eric, mind you, The patient was quite stable, and I wanted to see how Eric would handle this situation.

As it turns out, the Deaf patient’s primary means of communication was indeed sign language. Fortunately for Eric, the patient was trying to integrate humor to put Eric at ease. Unfortunately, Eric proceeded to tell me, not the patient, that he could not treat the patient until an interpreter arrived. It was at that moment our patient afforded Eric an unsolicited lesson in sign language, involving anatomical parts being placed in other anatomical locations usually not reserved for cohabitation. And believe me, knowledge of sign language was not required to get the gist.

Stretching my fingers, I then took on the role of interpreter for both Eric and the patient. “Telling you that I am Deaf does not mean ‘Don’t communicate with me,’” signed the patient. This was punctuated with another sign for incorporating unsolicited body segments. Continuing, our patient stopped signing and reverted to using his intelligible speech. “It’s not how you exchange ideas, but that you do.”

Our patient apologized to Eric for the choice of signs he used to accentuate his passion for treating the D&HH with the same dignity and equality afforded everyone else. My partner in turn apologized and requested some helpful communication tips.

Here’s what he learned:
1. Don’t yell. You just look silly, and it draws unnecessary attention.
2. If the individual who is D&HH prefers to lip-read, speak clearly and don’t over enunciate. More unnecessary silliness.
3. If the patient requests an interpreter, request through dispatch that the hospital destination contact one before you leave the scene.
4. Speak directly to the individual and not the interpreter.
5. Protect the individual’s rights by only using bystander interpreters whom the patient agrees to have present.
6. Make sure you have the attention of the person, but don’t wildly wave your hands or stomp your feet to draw their attention. Now you really look silly.
7. Use direct and to-the-point short sentences when using writing as a means of communication. This saves time.
8. Don’t be afraid to be animated. Any signing is better than no signing. Gestures work well.
9. English is typically the Deaf person’s second language with different rules for grammar and syntax.
10. Hearing aids don’t work well in loud environments.
11. Never use the term “Deaf and dumb” unless you want to see more signs related to incompatible organs.

From an EMS perspective, I offer the following suggestions:
1. Spinal immobilization and C-collars by themselves significantly reduce the visual periphery of the D&HH.
2. Take out the individual’s hearing aids if you spinal immobilize them. Don’t lose them, either. They’re veeeery expensive.
3. Don’t wear gloves when you sign. Otherwise you’re mumbling. Just kidding.
4. Don’t expect a patient who is D&HH to lip-read when the light is poor or the sun is in their eyes. Oh, and don’t wear a mask. Now that is silliness at an awesome level.
5. Wash your hands before you sign as you don’t want to talk dirty. Just kidding again.
6. Yelling “clear” with multiple hearing-impaired persons on scene could have negative consequences. Ha. I crack myself up.
7. Be aware a professional interpreter will sign everything they hear in the presence of the D&HH. That includes auditory flatulence (Not really necessary in my opinion as their olfactory system is still intact).

Until next time, remember that kindness is the language the Deaf can hear and the blind can see.

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An EMT’s Close Call Provides a Lesson about Health & Wellness

Kristin Spencer, MS, NREMT-P | Vince Mosesso, MD, EMT-P | From the April 2013 Issue | Wednesday, March 27, 2013

EMT John Davis considers himself a “tough guy.” He was raised on a farm and still lives on one, the kind of place where men perform long hours of manual labor and seldom complain. Farmers don’t call in sick, and many will tell you that unless they’re critically injured, they continue working, because there’s always work to be done. John enjoys his rural lifestyle and the serenity that comes with it. But at the age of 48, he decided he wanted to become an EMT. In December 2010, he did.

As an EMT for Metro Emergency Transport System (METS) in Joplin, Mo., John is no stranger to patients who complain of chest pain. He responds to those emergencies frequently and often finds himself advising those patients not to ignore their symptoms. Yet when John started experiencing chest pain while he was on duty on May 5, 2012, he was hesitant to share his symptoms with his paramedic partner, Priscilla Jobe.

Priscilla, a paramedic at METS since 2007 and 20 years John’s junior, will confess to anyone that she seldom gets any “good” calls. According to Priscilla, she gets more transfers and alpha (basic-level) calls than anyone deserves. Surprisingly, she has never treated a patient with an acute myocardial infarction (AMI) and can count on one hand the number of critical trauma patients she has had. John, on the other hand, admits to being a magnet for trauma calls and calls that turn complicated, and he prefers it that way.

Priscilla is outgoing, energetic and gifted with a sense of humor her colleagues appreciate, while John is more subdued. It seems fate joined the two together as a means of creating some sort of balance—a yin and yang between polar opposites.

The Incident
Less than a year after John became employed with METS, he clocked in at the main station. He and Priscilla had just checked out their ambulance, Metro 6, when they received a call to a residence all too familiar to them—a “frequent flyer” they deemed needed a taxi instead of an ambulance transport. During the call John felt fine. The two dropped off the patient at Freeman West emergency department and were sitting in what local medics refer to as the “fishbowl,” the glass-enclosed area designated for ambulance personnel.

John began writing his run report when he started to feel ill. Nevertheless, he recalls he dutifully continued writing his run report even as he started experiencing the onset of a burning sensation in his chest. Like so many of the chest pain patients he assessed in the past, John discounted the pain he was experiencing, thinking it was merely heartburn.

John is like thousands of other EMTs who eat on the run, smoke cigarettes and just can’t find the time to incorporate exercise into their busy lives. He has to work overtime to pay the bills—a 90-hour week was not uncommon for him—but he rarely considered the ramifications of his fast-paced lifestyle. In the back of his mind, John knew he needed to quit smoking, lose weight and eat healthier, but he always managed to save that lifestyle change for tomorrow, next week or next month.

As John continued writing his report, the pain exacerbated, and he started turning pale and a little sweaty, according to Priscilla. Noting the changes in his skin color, Priscilla jokingly asked John if he was having a heart attack. In a somber tone John replied, “I don’t want to alarm you, but I don’t feel so good.” That signaled a red flag for Priscilla. Taking John by the arm and assisting him outside to their ambulance only a few feet away, Priscilla placed him on a cardiac monitor and checked his vital signs. Although his blood pressure was normal, he was bradycardic, short of breath and pale. “The ECG recording was junk. I couldn’t read anything,” Priscilla says. Rating his pain as a 6 out of 10 and stating he couldn’t catch his breath, John tried to remain stoic as Priscilla prepared to do a 12-lead ECG.

Priscilla says as she was acquiring her 12-lead ECG, she couldn’t believe her eyes: John was having an AMI. And not just any myocardial infarction, but one referred to in the medical vernacular as a “widow-maker,” which involves the left anterior descending artery (LAD). ST-segment elevation was evident in leads I, aVL, V2, V3, V4, V5 and V6 with reciprocal depression in leads II, III, and a VF. Priscilla asked John if he had ever had a myocardial infarction; he shook his head. “You have now,” she told him.

The last time John had been to the doctor was approximately 10 years earlier. He will be the first to tell you he doesn’t care for doctors. His last visit to the doctor resulted in a hospital admission during which he nearly died from internal bleeding from a liver biopsy gone wrong. He hadn’t stepped foot in a doctor’s office since. But during this moment, something told John this was no time for stubbornness and he needed to be evaluated by an emergency physician. When Priscilla told him she was going to retrieve a wheelchair for him, he simply nodded his head.

Priscilla, who was six months pregnant, needed assistance but couldn’t find anyone in the parking bay. Knowing a physician was just a few feet away, she retrieved a wheelchair from the entryway and ordered John to get in to it. Entering the ED doors waving the ECG, Priscilla held the ECG up against the receptionist’s window and said, “That’s my partner’s ECG.” She told the ED receptionist her partner was having a heart attack and to open the doors to the patient area.

Once there, a nurse saw Priscilla in uniform, wheeling her ill partner, who presented with Levine’s sign, pallor and diaphoresis. A concerned nurse asked Priscilla what was going on. Priscilla handed the ECG to the nurse, who said, “Get him into room 29. I’ll get the doctor.”

It was there that John realized how dire his situation was. His bedside was surrounded with nurses, an ECG technician, members of the STEMI team and the ED physician. The physician placed pacing-defibrillator patches on his chest and back while nurses placed him on oxygen, initiated IVs and administered anti-platelet agents. A nitroglycerin drip was hung, paperwork was signed and the cath lab notified. John vaguely remembers the ED staff rushing him down the hall to the cath lab at full speed.

Due to the speed and precision of the ED staff, the time from the onset of John’s symptoms to the cath lab was only 20 minutes and 40 minutes to revascularization. Had he not been where he was, the outcome might have been different. John is acutely aware of that.

The Revascularization
John Cox, MD, an interventional cardiologist for the Freeman Health System in Joplin, refrains from using the term “widow-maker” in his vernacular. He thinks the term is often misused and incorrectly implies no chance of survival. A true widow-maker occurs when stenosis occurs in the first part of the LAD, he says. Yet he understands how fortunate John was to have been standing only feet away from knowledgeable healthcare professionals. Current American Heart Association (AHA) guidelines recommend a door-to-intervention time of 90 minutes or less; Freeman West boasts a 51-minute average door-to-intervention time.1

Having poor ejection fraction, John was “highly symptomatic” and, during the procedure, went in to ventricular fibrillation (VF). After one shock, however, Cox successfully restored a pulse. “Anytime we have a patient in the cath lab, we anticipate a defibrillation scenario, and we’re prepared to deal with that,” he says.

By the time John made it in the cath lab, Priscilla had contacted her field supervisor and the director of operations, Jason Smith. She waited anxiously. After about an hour, John was successfully revascularized through percutaneous transluminal coronary angioplasty, although a stent was also required to maintain coronary perfusion.

The Lesson Learned
John admits he rarely gave a second thought to his lifestyle habits, but he’s now cognizant of how his unhealthy lifestyle contributed to his AMI. Increasingly, researchers are addressing how to help reduce the incidence of cardiovascular disease.

Recently the Centers for Disease Control and Prevention (CDC) published findings of a 22-year observational study based on a national survey of nutritional and health habits.2 The specific conditions and habits considered were:
1. Smoking;
2. Physical inactivity;
3. High blood pressure;
4. Elevated cholesterol/lipid levels;
5. Elevated blood glucose levels;
6. Poor diet; and
7. Obesity.
The study found that less than 2% of Americans exhibited none of these seven factors. If you have six or seven of these factors, your risk is four times higher for cardiovascular disease and three times higher for death than someone with none or only one of them. All of these factors are treatable or preventable, for the most part, through lifestyle and medications.

They say that hindsight is 20/20. While recuperating in the hospital after his angioplasty, John reflected over the days preceding his ST-segment elevated myocardial infarction and recalled the chest pain he experienced while working in his lawn just a few days before the potentially lethal event. John admits at the time his body was giving him warning signs of things to come. He discounted the symptoms, reasoning the pain was due to overexertion, heat illness or dehydration. It never occurred to him that the episode of chest pain he experienced during exertion should have been communicated to a physician. He takes care of patients; he’s not supposed to become one.

Discharged from the hospital feeling invigorated again, John couldn’t wait to get back to work, but with a few changes: He has altered his dietary habits and has since quit smoking. He understands that because of his lifestyle, he was teasing death, and in hindsight knows that was a dangerous game to play. Fortunately for John, as serious and deadly as the “widow-maker” might be, it didn’t win. He can live to improve his lifestyle.

Do You Need a Change?
Although this is a personal story about John, it holds a lesson for all EMS providers. Too many of us put aside our own health to take care of others, or to fit in another shift. We must not underestimate the effect that our high-stress jobs have on our health. Ask yourself: Could what happened to John happen to you? If so, it’s time to start targeting those seven factors—before you become the patient.

Kristin Spencer, MS, NREMT-P, the EMS program director and instructor, and AMLS Affiliate Faculty with Crowder College in Missouri. She can be reached at kristinspencer@crowder.edu.
Vince Mosesso, MD, EMT-P, is a professor of emergency medicine at the University of Pittsburgh School of Medicine and medical director of UPMC Prehospital Care. He is also NAEMT AMLS medical director.

References
1. Moscucci M, Eagle KA. Door-to-balloon time in primary percutaneous coronary intervention: Is the 90-minute gold standard an unreachable chimera? Circulation. 2006;113(8):1048–1050.
2. Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273–1283. Epub 2012 Mar 16.

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2011 EMS 10 Winner David Reinis

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Ohio Medics Carrying Guns for Personal Protection

Richard Huff, NREMT-B | From the January 2008 Issue | Thursday, May 30, 2013

In a profession where staffers are known to pack extra equipment into their belt loops, a few EMS and fire providers in Bethel Township, Ohio, are adding just a little more kick—firearms.

For about a year, the Bethel Township Fire and EMS Department has allowed first responders to carry concealed weapons on emergency calls as a way to protect themselves in an area where having law enforcement respond to calls in a timely manner when needed can be a challenge due to reduced staffing.

The idea to let first responders carry weapons was hatched after budget cuts reduced the number of available officers in the response area served by the department, says Bethel Township Fire and EMS Department Chief Jacob King.

“Law enforcement is a huge piece of this,” King says. “When you’re lacking a lot of assistance, you have to change the way you do business.”

King’s department handles 2,100 calls a year, some 1,600 of them for medical emergencies. King says there have been times when his staff hasn’t felt a scene was safe and the delay in getting law enforcement support has made the wait to render aid too long.

“The ones that do carry [guns] feel safer,” King says, adding that just a few members participate in the program.

Under the Bethel Township program, staff members who hold concealed carry gun permits through the state of Ohio may carry them while on duty. Before doing so, King says, they’re provided significant training on when and how to use them. So far, he says, not one provider has used their weapon in the line of duty.

Violent Incidents
Word of the Bethel Township Fire Department gun program has surfaced at a time when there have been intense conversations within the field on EMS staff safety and what may be done about it. Although first responder safety is always an issue, concerns escalated to a heightened level of awareness in December when a man in Webster, N.Y., set fire to his home and then shot at firefighters responding to the blaze. Four were shot and two were killed in the ambush.

Then in April 2013, a man in Gwinnett County, Ga., called in a medical emergency. When firefighters responded to the house, he took them hostage. Police SWAT team members eventually gained access to the home and killed the man. The firefighters later said the man admitted to them he called for medical help because he didn’t think they would be armed.

Even before those incidents, there had been an increased focus on responder safety. Indeed, street safety classes teach EMS responders how to react in unsafe conditions. And more agencies are getting bulletproof vests for their employees. For instance, in March, Dorchester County, Md., officials voted to allow the county’s emergency services department to shop for bulletproof vests after a crew showed up for a seizure call only to find out the seizure was secondary to a gunshot wound and the scene was unsecured when the team got there.

The decision to carry guns is a personal one for every department, says King, and it may not be right for every situation. In the case of Bethel Township, they’re simply providing the same rights that every other Ohio resident has to carry a concealed gun. “And in no way, shape or form do we ever want to inflict harm against any of our citizens,” adds King.

Likewise, King says, the decision to let staff carry their own weapons isn’t an effort for them to replace law enforcement. Instead, it’s a way for his staff to feel comfortable helping people where they might not otherwise feel safe.

“We saw several calls that would require immediate [medical] intervention to help save a person’s life and we would just sit and wait,” King says.

“They didn’t have the opportunity to even do something,” he adds. “When I don’t have the opportunity to even try to save someone’s life—that gets to me more than when I make a mistake.”

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2012 EMS 10 Winner Dale Becker, EMT-P

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Set SMART Goals to Make Up for Abandoned New Year’s Resolutions

Elizabeth Smith, EMT-B | | Friday, April 19, 2013

New Year’s Day has come and gone. Most of you probably made a New Year’s resolution, since about 45% of Americans make at least one New Year’s resolution each year.(1)

As many of us know, however, deciding to make a change and actually making it are distinctly different. After six months, 54% of resolutions have fallen by the wayside.(1) It’s been about four months already. Have you kept your resolution?

If you haven’t, you probably made the most common mistake: being overzealous in resolution making. This includes deciding all at once to stop drinking, smoking, and swearing, and  to start losing weight and exercising more. We set the bar so high, it’s nearly impossible to succeed. One small misstep leads to another, and soon good intentions are abandoned in favor of the comfort of familiar behaviors.

If your first round of resolutions fell flat, consider making some new ones. The resolution solution is to make goals that are actually achievable. If your goal is to lose 100 lbs. and you only lose 80, then you’ve failed despite the fact that losing 80 lbs. in a healthy way is a tremendous achievement. Instead,  set your goal to lose five pounds, achieve it, decide to lose five more, and so on. By the time you lose 80 lbs., you’ve been successful 16 times. That can do wonders for your mental health. The point is, it’s all in your approach; when making goals, you need to be smart.

SMART goals are specific, measurable, appropriate, realistic and timely.
• Specific: Define exactly what you hope to accomplish.
• Measurable: Set concrete criteria, including amount or frequency.
• Appropriate: Choose a goal that’s within your grasp. Consider your schedule, finances and physical situation.
• Realistic: Choose a goal for which you’re able and willing to work.
• Timely: Set a time frame for your goal, in days, weeks, or months. The shorter the time frame, the more manageable you will likely make your goal.

For a practical example, let’s look at a common New Year’s resolution: “I want to lose weight.” Among Americans who make resolutions, losing weight is the goal most frequently chosen.(1) Stated like that, however, the goal is open to interpretation and can be easily distorted: Do you want to lose five pounds? Fifty? One hundred and fifty? And how, exactly, will you go about doing it? Do you mean to exercise, eat more healthfully, or run 20 miles a day while still eating a whole pepperoni pizza?

A SMART goal would look more like the following: “I will lose 10 pounds by July by going to the gym for 20 minutes, three times a week; and packing my lunch twice a week instead of eating out.” The goal is specific: I plan to lose a specific amount of weight. It’s measurable: Pounds can be measured by a bathroom scale; you can count the number and duration of trips to the gym; and you can count the number of lunches to be packed each week. It’s appropriate: losing 10 pounds in three months is a safe and healthy rate of weight loss, and using diet and exercise is the accepted way to accomplish this. It’s realistic: a busy EMS provider can likely fit in packing two lunches and make time for three 20-minute sessions. This is a much more reasonable expectation than choosing to run for an hour seven days a week and eat nothing but kale. And it’s timely: saying “by July” provides an identifiable end point in the near future.

Another good approach is to think not in terms of the year’s resolutions, but rather in terms of the day’s resolutions. Focus on small changes you can make every day, such as remembering to eat breakfast, choosing one healthier option each day and opting for one glass of water over one can of soda. These changes alone aren’t intimidating, and if you make a few healthy choices every day, they will add up to big results for a healthier, happier you.

Here are a few other resolutions to consider that are more specific than simply “get healthy:”
1. Stay in touch: People with stronger social ties live longer than those without.
2. Decrease your stress: Chronic stress increases risk for many diseases.
3. Go to the doctor: Stay up to date on visits and vaccines. Focus on prevention.
4. Floss your teeth: It’s an easy way to fight and prevent gum disease, and some studies have said it can reduce your long-term risk for heart disease.
5. Wear sunscreen: The sun can damage your skin even in winter. Protect yourself.
6. Take time for yourself: Use it to de-stress, organize your thoughts and relax.
7. Don’t multitask while you eat: You’ll eat less and enjoy your food more.
8. Volunteer: People who volunteer are happier. Happiness is good for your health.
9. Get more sleep: Sleep improves your memory, mood and appearance.
10. Cut back on alcohol: Excessive drinking increases depression and memory loss.
11. Save money: Save wherever you can to decrease debt and decrease stress.
12. Try something new: Life is an adventure. Get out of your rut.

References
1. Norcross JC, Mrykalo MS, Blagys MD. Auld lang syne: Success predictors, change processes and self-reported outcomes of New Year's resolvers and nonresolvers. J Clin Psychol. 2002;58(4):397–405.

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2011 EMS 10 Winner Rob Lawrence

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An EMT’s Close Call Provides a Lesson about Health & Wellness

Kristin Spencer, MS, NREMT-P | Vince Mosesso, MD, EMT-P | From the April 2013 Issue | Wednesday, March 27, 2013

EMT John Davis considers himself a “tough guy.” He was raised on a farm and still lives on one, the kind of place where men perform long hours of manual labor and seldom complain. Farmers don’t call in sick, and many will tell you that unless they’re critically injured, they continue working, because there’s always work to be done. John enjoys his rural lifestyle and the serenity that comes with it. But at the age of 48, he decided he wanted to become an EMT. In December 2010, he did.

As an EMT for Metro Emergency Transport System (METS) in Joplin, Mo., John is no stranger to patients who complain of chest pain. He responds to those emergencies frequently and often finds himself advising those patients not to ignore their symptoms. Yet when John started experiencing chest pain while he was on duty on May 5, 2012, he was hesitant to share his symptoms with his paramedic partner, Priscilla Jobe.

Priscilla, a paramedic at METS since 2007 and 20 years John’s junior, will confess to anyone that she seldom gets any “good” calls. According to Priscilla, she gets more transfers and alpha (basic-level) calls than anyone deserves. Surprisingly, she has never treated a patient with an acute myocardial infarction (AMI) and can count on one hand the number of critical trauma patients she has had. John, on the other hand, admits to being a magnet for trauma calls and calls that turn complicated, and he prefers it that way.

Priscilla is outgoing, energetic and gifted with a sense of humor her colleagues appreciate, while John is more subdued. It seems fate joined the two together as a means of creating some sort of balance—a yin and yang between polar opposites.

The Incident
Less than a year after John became employed with METS, he clocked in at the main station. He and Priscilla had just checked out their ambulance, Metro 6, when they received a call to a residence all too familiar to them—a “frequent flyer” they deemed needed a taxi instead of an ambulance transport. During the call John felt fine. The two dropped off the patient at Freeman West emergency department and were sitting in what local medics refer to as the “fishbowl,” the glass-enclosed area designated for ambulance personnel.

John began writing his run report when he started to feel ill. Nevertheless, he recalls he dutifully continued writing his run report even as he started experiencing the onset of a burning sensation in his chest. Like so many of the chest pain patients he assessed in the past, John discounted the pain he was experiencing, thinking it was merely heartburn.

John is like thousands of other EMTs who eat on the run, smoke cigarettes and just can’t find the time to incorporate exercise into their busy lives. He has to work overtime to pay the bills—a 90-hour week was not uncommon for him—but he rarely considered the ramifications of his fast-paced lifestyle. In the back of his mind, John knew he needed to quit smoking, lose weight and eat healthier, but he always managed to save that lifestyle change for tomorrow, next week or next month.

As John continued writing his report, the pain exacerbated, and he started turning pale and a little sweaty, according to Priscilla. Noting the changes in his skin color, Priscilla jokingly asked John if he was having a heart attack. In a somber tone John replied, “I don’t want to alarm you, but I don’t feel so good.” That signaled a red flag for Priscilla. Taking John by the arm and assisting him outside to their ambulance only a few feet away, Priscilla placed him on a cardiac monitor and checked his vital signs. Although his blood pressure was normal, he was bradycardic, short of breath and pale. “The ECG recording was junk. I couldn’t read anything,” Priscilla says. Rating his pain as a 6 out of 10 and stating he couldn’t catch his breath, John tried to remain stoic as Priscilla prepared to do a 12-lead ECG.

Priscilla says as she was acquiring her 12-lead ECG, she couldn’t believe her eyes: John was having an AMI. And not just any myocardial infarction, but one referred to in the medical vernacular as a “widow-maker,” which involves the left anterior descending artery (LAD). ST-segment elevation was evident in leads I, aVL, V2, V3, V4, V5 and V6 with reciprocal depression in leads II, III, and a VF. Priscilla asked John if he had ever had a myocardial infarction; he shook his head. “You have now,” she told him.

The last time John had been to the doctor was approximately 10 years earlier. He will be the first to tell you he doesn’t care for doctors. His last visit to the doctor resulted in a hospital admission during which he nearly died from internal bleeding from a liver biopsy gone wrong. He hadn’t stepped foot in a doctor’s office since. But during this moment, something told John this was no time for stubbornness and he needed to be evaluated by an emergency physician. When Priscilla told him she was going to retrieve a wheelchair for him, he simply nodded his head.

Priscilla, who was six months pregnant, needed assistance but couldn’t find anyone in the parking bay. Knowing a physician was just a few feet away, she retrieved a wheelchair from the entryway and ordered John to get in to it. Entering the ED doors waving the ECG, Priscilla held the ECG up against the receptionist’s window and said, “That’s my partner’s ECG.” She told the ED receptionist her partner was having a heart attack and to open the doors to the patient area.

Once there, a nurse saw Priscilla in uniform, wheeling her ill partner, who presented with Levine’s sign, pallor and diaphoresis. A concerned nurse asked Priscilla what was going on. Priscilla handed the ECG to the nurse, who said, “Get him into room 29. I’ll get the doctor.”

It was there that John realized how dire his situation was. His bedside was surrounded with nurses, an ECG technician, members of the STEMI team and the ED physician. The physician placed pacing-defibrillator patches on his chest and back while nurses placed him on oxygen, initiated IVs and administered anti-platelet agents. A nitroglycerin drip was hung, paperwork was signed and the cath lab notified. John vaguely remembers the ED staff rushing him down the hall to the cath lab at full speed.

Due to the speed and precision of the ED staff, the time from the onset of John’s symptoms to the cath lab was only 20 minutes and 40 minutes to revascularization. Had he not been where he was, the outcome might have been different. John is acutely aware of that.

The Revascularization
John Cox, MD, an interventional cardiologist for the Freeman Health System in Joplin, refrains from using the term “widow-maker” in his vernacular. He thinks the term is often misused and incorrectly implies no chance of survival. A true widow-maker occurs when stenosis occurs in the first part of the LAD, he says. Yet he understands how fortunate John was to have been standing only feet away from knowledgeable healthcare professionals. Current American Heart Association (AHA) guidelines recommend a door-to-intervention time of 90 minutes or less; Freeman West boasts a 51-minute average door-to-intervention time.1

Having poor ejection fraction, John was “highly symptomatic” and, during the procedure, went in to ventricular fibrillation (VF). After one shock, however, Cox successfully restored a pulse. “Anytime we have a patient in the cath lab, we anticipate a defibrillation scenario, and we’re prepared to deal with that,” he says.

By the time John made it in the cath lab, Priscilla had contacted her field supervisor and the director of operations, Jason Smith. She waited anxiously. After about an hour, John was successfully revascularized through percutaneous transluminal coronary angioplasty, although a stent was also required to maintain coronary perfusion.

The Lesson Learned
John admits he rarely gave a second thought to his lifestyle habits, but he’s now cognizant of how his unhealthy lifestyle contributed to his AMI. Increasingly, researchers are addressing how to help reduce the incidence of cardiovascular disease.

Recently the Centers for Disease Control and Prevention (CDC) published findings of a 22-year observational study based on a national survey of nutritional and health habits.2 The specific conditions and habits considered were:
1. Smoking;
2. Physical inactivity;
3. High blood pressure;
4. Elevated cholesterol/lipid levels;
5. Elevated blood glucose levels;
6. Poor diet; and
7. Obesity.
The study found that less than 2% of Americans exhibited none of these seven factors. If you have six or seven of these factors, your risk is four times higher for cardiovascular disease and three times higher for death than someone with none or only one of them. All of these factors are treatable or preventable, for the most part, through lifestyle and medications.

They say that hindsight is 20/20. While recuperating in the hospital after his angioplasty, John reflected over the days preceding his ST-segment elevated myocardial infarction and recalled the chest pain he experienced while working in his lawn just a few days before the potentially lethal event. John admits at the time his body was giving him warning signs of things to come. He discounted the symptoms, reasoning the pain was due to overexertion, heat illness or dehydration. It never occurred to him that the episode of chest pain he experienced during exertion should have been communicated to a physician. He takes care of patients; he’s not supposed to become one.

Discharged from the hospital feeling invigorated again, John couldn’t wait to get back to work, but with a few changes: He has altered his dietary habits and has since quit smoking. He understands that because of his lifestyle, he was teasing death, and in hindsight knows that was a dangerous game to play. Fortunately for John, as serious and deadly as the “widow-maker” might be, it didn’t win. He can live to improve his lifestyle.

Do You Need a Change?
Although this is a personal story about John, it holds a lesson for all EMS providers. Too many of us put aside our own health to take care of others, or to fit in another shift. We must not underestimate the effect that our high-stress jobs have on our health. Ask yourself: Could what happened to John happen to you? If so, it’s time to start targeting those seven factors—before you become the patient.

Kristin Spencer, MS, NREMT-P, the EMS program director and instructor, and AMLS Affiliate Faculty with Crowder College in Missouri. She can be reached at kristinspencer@crowder.edu.
Vince Mosesso, MD, EMT-P, is a professor of emergency medicine at the University of Pittsburgh School of Medicine and medical director of UPMC Prehospital Care. He is also NAEMT AMLS medical director.

References
1. Moscucci M, Eagle KA. Door-to-balloon time in primary percutaneous coronary intervention: Is the 90-minute gold standard an unreachable chimera? Circulation. 2006;113(8):1048–1050.
2. Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273–1283. Epub 2012 Mar 16.

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Avoid Supermarket Ploys to Eat Healthier

Elizabeth Smith, EMT-B | From the January 2008 Issue | Wednesday, April 24, 2013

Good nutrition starts in the grocery store, because having healthy ingredients on hand is the first step for preparing healthy meals. For a lot of people, the amount of food on grocery store shelves can be overwhelming. The average supermarket stocks thousands of items, and there are more new items available each day. Products are strategically advertised and placed to catch our eyes and convince us that we need them. Grocery stores intend to sell food, after all. Information on labels can be confusing and misleading, causing us to buy “healthy” products that we think are good for us but aren’t healthy at all. All of this, combined with personal habits, lack of knowledge and lack of time, can mean walking out of the store $50 lighter with nothing to show for it but a box of soy cookies and 15 packs of microwavable noodles.

Product Placement
One of the best tactics for being an informed consumer is to understand the anatomy of the grocery store. It’s most important to know the healthiest foods are on the perimeter. In the vast majority of markets, the produce section, dairy refrigerator, meat and fish counters, and bakery with fresh-baked breads all lie on the outer edges of the store. The middle of the store contains mainly processed, pre-packaged convenience foods. These foods are high in sodium and often low in nutritional value, so you should eat them sparingly. This layout is intentional. We have to walk past all these money-making processed foods to get to the back of the store for the staples we actually need.

Another strategy for being a healthier consumer is to be aware of the way items are placed on the shelf. The area right at the customer’s eye level is considered prime space. Stores actually charge more to place products there, so those shelves tend to carry national brands and bestselling products. The lower shelves, set in the line of sight of a child, usually carry products with bright colors and lots of sugar, meant to appeal to children who are at the right height to reach out and grab them. The very bottom shelf tends to have larger items, often bulk, that can be comparable to and more affordable than items placed more visibly. So if we head in without a plan, we’re more likely to buy the items that are most easily seen and most brightly colored (especially if there’s a child helping with the shopping), rather than those that are the best price or most healthful.

Shop with a Strategy
The soundest strategy for avoiding these marketing tactics is to start your shopping adventure armed with a plan. Before heading to the store, make a list of the meals you want to prepare for the week. For each day, plan out breakfast, lunch and dinner. This doesn’t need to be fancy. You may eat cereal for breakfast every day, so that’s all you need to write in your menu.
From your menu, make a shopping list. Include each item you will need for your planned meals and its quantity. For example, if you’re making grilled chicken breast for two, you would write: “Boneless, skinless chicken breast (2).” This tells you exactly what you need to pick up off the shelf (see a sample meal plan at right and a sample shopping list below). As you become more familiar with your grocery store, you can arrange your list in order of the store layout, making it easier to avoid retracing your steps and reducing the amount of time you spend shopping.

When you’re ready to go shopping, make sure to eat a small snack or meal before you leave. Going to the store hungry drastically increases the chances you will buy junk food. Once you arrive, stick to your list. Remember the tactics vendors use to convince you to spend more, and don’t buy into them. Buy only what you need, and you will save money while avoiding the temptation brought by having a cabinet full of sandwich cookies and potato chips.

Produce
Strawberries (1 pint)
Green peppers (2)
Onions (2)
Romaine lettuce (2 heads)
Asparagus (1 bunch)
Button mushrooms (1 package)
Green beans (3 cups)
Idaho potatoes (1 bag)

Refrigerated
Eggs (1 dozen large)
Skim milk (1 gallon)
Low fat shredded cheddar cheese (1 package)
Low fat shredded mozzarella cheese (1 package)
Fat-free sour cream (1 container)
Spray butter
Sliced turkey breast (1 package)
Chicken breasts (4)
Pork chops (2)
Lean ground beef (1 pound)

Frozen
Frozen vegetables (1 package)
Black bean burgers (1 box)

Prepared
Frosted Mini Wheats (1 box)
Whole wheat bread (1 loaf)
Whole wheat spaghetti (1 box)
Marinara sauce (1 jar)
Pizza sauce (1 jar)
Prepared pizza crust (1)
Breadcrumbs (1 container)
Taco shells (1 box)
Salsa (1 jar)
Brown rice (1 box)
Whole wheat tortilla chips (1 bag)

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2011 EMS 10 Winner Pat Songer

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Set SMART Goals to Make Up for Abandoned New Year’s Resolutions

Elizabeth Smith, EMT-B | | Friday, April 19, 2013

New Year’s Day has come and gone. Most of you probably made a New Year’s resolution, since about 45% of Americans make at least one New Year’s resolution each year.(1)

As many of us know, however, deciding to make a change and actually making it are distinctly different. After six months, 54% of resolutions have fallen by the wayside.(1) It’s been about four months already. Have you kept your resolution?

If you haven’t, you probably made the most common mistake: being overzealous in resolution making. This includes deciding all at once to stop drinking, smoking, and swearing, and  to start losing weight and exercising more. We set the bar so high, it’s nearly impossible to succeed. One small misstep leads to another, and soon good intentions are abandoned in favor of the comfort of familiar behaviors.

If your first round of resolutions fell flat, consider making some new ones. The resolution solution is to make goals that are actually achievable. If your goal is to lose 100 lbs. and you only lose 80, then you’ve failed despite the fact that losing 80 lbs. in a healthy way is a tremendous achievement. Instead,  set your goal to lose five pounds, achieve it, decide to lose five more, and so on. By the time you lose 80 lbs., you’ve been successful 16 times. That can do wonders for your mental health. The point is, it’s all in your approach; when making goals, you need to be smart.

SMART goals are specific, measurable, appropriate, realistic and timely.
• Specific: Define exactly what you hope to accomplish.
• Measurable: Set concrete criteria, including amount or frequency.
• Appropriate: Choose a goal that’s within your grasp. Consider your schedule, finances and physical situation.
• Realistic: Choose a goal for which you’re able and willing to work.
• Timely: Set a time frame for your goal, in days, weeks, or months. The shorter the time frame, the more manageable you will likely make your goal.

For a practical example, let’s look at a common New Year’s resolution: “I want to lose weight.” Among Americans who make resolutions, losing weight is the goal most frequently chosen.(1) Stated like that, however, the goal is open to interpretation and can be easily distorted: Do you want to lose five pounds? Fifty? One hundred and fifty? And how, exactly, will you go about doing it? Do you mean to exercise, eat more healthfully, or run 20 miles a day while still eating a whole pepperoni pizza?

A SMART goal would look more like the following: “I will lose 10 pounds by July by going to the gym for 20 minutes, three times a week; and packing my lunch twice a week instead of eating out.” The goal is specific: I plan to lose a specific amount of weight. It’s measurable: Pounds can be measured by a bathroom scale; you can count the number and duration of trips to the gym; and you can count the number of lunches to be packed each week. It’s appropriate: losing 10 pounds in three months is a safe and healthy rate of weight loss, and using diet and exercise is the accepted way to accomplish this. It’s realistic: a busy EMS provider can likely fit in packing two lunches and make time for three 20-minute sessions. This is a much more reasonable expectation than choosing to run for an hour seven days a week and eat nothing but kale. And it’s timely: saying “by July” provides an identifiable end point in the near future.

Another good approach is to think not in terms of the year’s resolutions, but rather in terms of the day’s resolutions. Focus on small changes you can make every day, such as remembering to eat breakfast, choosing one healthier option each day and opting for one glass of water over one can of soda. These changes alone aren’t intimidating, and if you make a few healthy choices every day, they will add up to big results for a healthier, happier you.

Here are a few other resolutions to consider that are more specific than simply “get healthy:”
1. Stay in touch: People with stronger social ties live longer than those without.
2. Decrease your stress: Chronic stress increases risk for many diseases.
3. Go to the doctor: Stay up to date on visits and vaccines. Focus on prevention.
4. Floss your teeth: It’s an easy way to fight and prevent gum disease, and some studies have said it can reduce your long-term risk for heart disease.
5. Wear sunscreen: The sun can damage your skin even in winter. Protect yourself.
6. Take time for yourself: Use it to de-stress, organize your thoughts and relax.
7. Don’t multitask while you eat: You’ll eat less and enjoy your food more.
8. Volunteer: People who volunteer are happier. Happiness is good for your health.
9. Get more sleep: Sleep improves your memory, mood and appearance.
10. Cut back on alcohol: Excessive drinking increases depression and memory loss.
11. Save money: Save wherever you can to decrease debt and decrease stress.
12. Try something new: Life is an adventure. Get out of your rut.

References
1. Norcross JC, Mrykalo MS, Blagys MD. Auld lang syne: Success predictors, change processes and self-reported outcomes of New Year's resolvers and nonresolvers. J Clin Psychol. 2002;58(4):397–405.

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2011 EMS 10 Winner Tom Bouthillet

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The Final EMS Call of Cody Medley & Tim McCormick

Guy H. Haskell | | Tuesday, April 2, 2013

I woke up for my shift on Medic 15 one Saturday morning in late February and rolled over to check the phone for messages. I was in no way prepared for the message I received from Indianapolis EMS Command.

Several hours earlier, at 3:37 a.m., Medic 50 was hit downtown, driving non-emergent with no patient on board as it crossed the intersection of St. Claire and Senate under a flashing yellow light. A two-door sedan blew a flashing red light and struck the Type III ambulance in front of the left rear wheels. Medic 50 flipped on its right side and slid down Senate until it was stopped when the cab was crushed against a parked car. Tim McCormick, 24 year-old EMT and private with Indianapolis EMS, was driving. Cody Medley, 22 year-old paramedic and IEMS specialist, was in the right seat. Both sustained fatal head injuries. Tim died at the scene. Cody died a day later in the ICU.

I had worked with Cody several times when he didn’t have a partner on Medic 18. He was young and brash and enthusiastic and always a pleasure to work with. I recognized Tim but hadn’t had the chance to work with him. Since that awful day, I have learned much about them both, and what remarkable young men they were. In the weeks since the crash, the public has had a chance to learn about Cody and Tim.

Others who knew them well have written about these two wonderful young men, their lives and their contributions. What I would like to do is give one paramedic’s thoughts on this past bittersweet week

In January 2011, I wrote a column titled “Happy Birthday Indianapolis Emergency Medical Services,” about the merger of Wishard Ambulance, the county hospital based EMS, and Indianapolis Fire Department EMS. On Dec. 26, 2010, they became one third service alongside police and fire. I wrote then that “EMS is the bastard stepchild of public safety. The Johnny-come-lately. The poor cousin. There isn’t an EMT in the country who would disagree. The only question is, how do we change our status?” One model, the one I preferred, was the one taken by the merger—the third-service model.

This past week, when Tim and Cody died, we were a little over two years into the merger. There have been ups and downs, advances and setbacks, some turf battles and bruised egos on both sides. These things are inevitable. But there has been real progress, not least of all the welcoming of IEMS into IAFF local 416.

I drove to work on Saturday morning very sad and not knowing what to expect. When I arrived at headquarters to begin my shift the parking lot was packed with command vehicles and news vans. I worked shifts on Saturday, Sunday, and Wednesday, and I am writing this on duty on Medic 54 a week later at a table on the apparatus floor behind Engine 54. I was able to watch the week unfold, and along with the sadness, each day brought me a sense of hope and wonder.

I admit that I was a cynic Saturday morning. How much would anyone outside our service really care about two young EMTs, only a couple of years on the job, dying in a traffic accident?

I was a paramedic in Worcester, Mass. in on the night of Dec. 3, 1999, when the Cold Storage Warehouse Fire claimed six firefighters in a black maze of death. I witnessed thousands of firefighters from all over North America and beyond come to embrace us in our sorrow. I was on duty in the EMS tent when thousands filed passed as local crews sifted through the rubble to find their brothers’ remains.  I saw the universal outpouring of grief and support when my hometown was devastated on Sept. 11, 2001, when 343 firefighters and paramedics and 59 police officers perished in the rubble. So how much would anybody care about two young EMTs?

I was wrong to be cynical. Every day I witnessed a flood of caring for those two young men and their families and their colleagues so far beyond what I had expected it was like a dream. Weeping police officers hugging in the street; tough inner city firefighters choking back sobs at a debriefing at the union hall; intense and caring media coverage; a stranger knocking on the window of Medic 21 on Wednesday night as I waited for my partner in front of Kroger to share his grief and offer his support and his thanks.

The city of Indianapolis, the Indianapolis Fire Department and the Indianapolis Metropolitan Police Department couldn’t have done more to honor Tim and Cody and support us in our sadness. The memorial for the boys on Wednesday filled the Butler University auditorium. IFD took on most duties to free IEMS to grieve. The Indianapolis Firefighters Emerald Society led the processional. The hall was filled with Class A Uniforms and brass from all the services; the love and support was palpable. The State Police provided an honor guard for the salute, and a bugler who played taps as clearly and as sweetly as I have ever heard it played. The Mayor and Council Chair and US Senator and others spoke words of kindness and appreciation. County Dispatch sent out the Last Call. Representatives from all over the State and beyond came to support us. When Tim’s body was returned to New York City to be interned in his home borough of Staten Island, the FDNY treated him as their own. The Fire Commissioner was there; the FDNY Emerald Society Pipes and Drums were there; the honor guards were there.

Never, never in my 30 years in EMS have I felt more honored, more appreciated. Thank you, brothers and sisters.

Cody and Tim,

I believe it was because of the force of your personalities, because of your caring and enthusiasm for this thankless work, because there were few that could know you and not like you, not love you, that we received the degree of support we did. You have brought us together; you have united us by your sacrifice; in blood you have formed a bond between us that might otherwise never have been forged. Thank you. You will not be forgotten.

All my love,
Guy

“3 ALERT TONES
ATTENTION ALL STATIONS and ALL PERSONELL.
EFFECTIVE February 20, 2013 INDIANAPOLIS EMS MEDIC 50, PARAMEDIC CODY MEDLEY and EMT TIM McCORMICK HAVE MADE THEIR FINAL CALL AND ARE NOW OUT OF SERVICE. THEY WILL BE MISSED BUT NEVER FORGOTTEN.”

Central Dispatch call to all units, 12 p.m., Feb. 20, 2013
Links:
Memorial t-shirts and hoodies—proceeds to Indianapolis Fire Rescue House: http://www.indyfrh.org/store/products/memorial-shirts-hoodies/
facebook: http://www.facebook.com/IndianapolisEMS
Indianapolis EMS: http://indianapolisems.org/
FDNY tribute on Staten Island: http://photos.silive.com/4499/gallery/staten_island_funeral_is_held_for_fallen_indianapolis_ems_private_timothy_c_mccormick/index.html
Memorial Program: http://indianapolisems.org/wp-content/uploads/2010/12/McCormickMedley-Program-Pgs.pdf 

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2011 EMS 10 Winner Michael Millin (Wilderness EMS)

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Allina EMS ResQPOD Experience 1

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2011 EMS 10 Winner Will Smith (Wilderness EMS)

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Preventing Violence Against EMS and First Responders

Michael J. Ward, BS, MGA, MIFireE, NREMT | From the March 2013 Issue | Friday, April 5, 2013

The Newtown (Conn.) school shooting and Webster (N.Y.) ambush of firefighters provide increased awareness of violence against emergency responders. East Hartford (Conn.) Fire Chief John Oates, writing for the National Fallen Fire Fighters (NFFF), has provided nine questions responders should ask:

1. Do you use risk/benefit analysis for every call?
2. Do you have an effective relationship at all levels with the law enforcement agencies in your community?
3. How good is the information you get from your dispatcher?
4. Do you allow members to “first respond” directly to the scene?
5. Does your law enforcement agency use an incident management system?
6. When responding to a potentially violent incident, do you seek out a law enforcement officer when you arrive?
7. Have you told your fire officers/personnel that it’s OK to leave the scene if things start to turn bad?
8. Is there a point at which you don’t respond or limit your response to violent incidents?
9. Is your uniform easily mistaken for law enforcement?

These questions came from a March 2012 focus group of 35 participants representing 29 organizations. The NFFF-commissioned report from this group, “Firefighter Life Safety Initiative 12 Final Report: National protocols for response to violent incidents should be developed and championed,” is part of a resource package covering 16 Firefighter Life Safety Initiatives of the Everyone Goes Home program.

Preventing Line-of-Duty Injury
Everyone Goes Home is a national program by the National Fallen Firefighters Foundation to prevent line-of-duty deaths and injuries. In March 2004, a Firefighter Life Safety Summit was held in Tampa, Fla., to address the cultural, philosophical, technical and procedural problems that affected safety within the fire service. The most important domains were identified, resulting in 16 Firefighter Life Safety Initiatives. Everyone Goes Home started as a way of implementing initiatives at the local level.

NFFF asked subject matter experts to develop a white paper for each initiative. Chief Oates provided the Initiative 12 report. The Novato, Calif., 2007 summit developed actionable objectives to support each of the Firefighter Life Safety Initiatives.

Noting that there was, “an absence of response protocols for violent incidents in many fire departments” a focus group met in Anne Arundel County, Md., in 2012 to develop an expanded report for Initiative 12, including the nine questions.

There’s no enforcement authority or funding to implement the Firefighter Life Safety Initiatives. Some feel that more effort should be directed against those who assault responders.

‘Paramedics Are Not Punching Bags’
New South Wales, Australia, ambulance service acting Commissioner Mike Willis announced a zero-tolerance policy toward violence against EMS personnel, noting on the agency’s website that there were six assaults against paramedics in early December.

There’s a perception that sanctions against those who assault EMS personnel are inadequate. In Illinois it’s a felony to assault a first responder; however, Chicago paramedics claimed, in a WLS-TV ABC News 7 report, that those who assault them get trivial punishment.

One technique that has been used is to fill a courtroom with emergency responders in uniform. In January, the New York Post reported that two dozen EMS workers filled a Manhattan courtroom to support their colleague who was allegedly choked by a drunken assistant district attorney.

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VividTrac offered by Vivid Medical - EMS Today 2013

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What Did You Say? A Humorous Look at Treating Deaf Patients

Steve Berry | From the January 2008 Issue | Monday, May 20, 2013

My nervous partner Eric loudly and with exaggeration asked the patient, “CAN. YOU. READ. MY. LIPS?”

The Deaf patient replied, “No. I. CAN'T. READ. YOUR. LIPS.”  The humor was lost on Eric as he relayed the patient’s limitations to me.

“Really?" I melodramatically replied. “I thought all Deaf inhabitants could visually convert external orifice configurations into meaningful linguistic interpretation.” The patient and I exchanged a brief grin.

“Now what are we going to do?” Eric was too nervous to notice my admiration for the patient’s cunning intellect. “I don’t know sign language,” he whined.

“Sure you do,” I deadpanned. “Show him your middle finger and see what happens.”

“Hey, I’m serious!” Eric blurted.

“How do you even know he uses sign language to communicate?” I questioned.

“Well, duh,” he asserted while confidently turning toward the patient with an affirming thumbs-up gesture. The patient returned the signal, mimicking my partner’s excessive body language and facial expressions.

Giving a satirical wink to the patient, I told Eric, “With pen and paper, ask the patient what method he would prefer to use when communicating with him.” With a deadpan expression the patient quickly jotted down one word and handed it back to Eric. “Brail.”

Poor Eric. He was a part-time newly licensed EMT who was not privy to the fact that I had once been a teacher for the Deaf and hard of hearing (D&HH) before I was naively drawn to EMS. Not that I volunteered that information to Eric, mind you, The patient was quite stable, and I wanted to see how Eric would handle this situation.

As it turns out, the Deaf patient’s primary means of communication was indeed sign language. Fortunately for Eric, the patient was trying to integrate humor to put Eric at ease. Unfortunately, Eric proceeded to tell me, not the patient, that he could not treat the patient until an interpreter arrived. It was at that moment our patient afforded Eric an unsolicited lesson in sign language, involving anatomical parts being placed in other anatomical locations usually not reserved for cohabitation. And believe me, knowledge of sign language was not required to get the gist.

Stretching my fingers, I then took on the role of interpreter for both Eric and the patient. “Telling you that I am Deaf does not mean ‘Don’t communicate with me,’” signed the patient. This was punctuated with another sign for incorporating unsolicited body segments. Continuing, our patient stopped signing and reverted to using his intelligible speech. “It’s not how you exchange ideas, but that you do.”

Our patient apologized to Eric for the choice of signs he used to accentuate his passion for treating the D&HH with the same dignity and equality afforded everyone else. My partner in turn apologized and requested some helpful communication tips.

Here’s what he learned:
1. Don’t yell. You just look silly, and it draws unnecessary attention.
2. If the individual who is D&HH prefers to lip-read, speak clearly and don’t over enunciate. More unnecessary silliness.
3. If the patient requests an interpreter, request through dispatch that the hospital destination contact one before you leave the scene.
4. Speak directly to the individual and not the interpreter.
5. Protect the individual’s rights by only using bystander interpreters whom the patient agrees to have present.
6. Make sure you have the attention of the person, but don’t wildly wave your hands or stomp your feet to draw their attention. Now you really look silly.
7. Use direct and to-the-point short sentences when using writing as a means of communication. This saves time.
8. Don’t be afraid to be animated. Any signing is better than no signing. Gestures work well.
9. English is typically the Deaf person’s second language with different rules for grammar and syntax.
10. Hearing aids don’t work well in loud environments.
11. Never use the term “Deaf and dumb” unless you want to see more signs related to incompatible organs.

From an EMS perspective, I offer the following suggestions:
1. Spinal immobilization and C-collars by themselves significantly reduce the visual periphery of the D&HH.
2. Take out the individual’s hearing aids if you spinal immobilize them. Don’t lose them, either. They’re veeeery expensive.
3. Don’t wear gloves when you sign. Otherwise you’re mumbling. Just kidding.
4. Don’t expect a patient who is D&HH to lip-read when the light is poor or the sun is in their eyes. Oh, and don’t wear a mask. Now that is silliness at an awesome level.
5. Wash your hands before you sign as you don’t want to talk dirty. Just kidding again.
6. Yelling “clear” with multiple hearing-impaired persons on scene could have negative consequences. Ha. I crack myself up.
7. Be aware a professional interpreter will sign everything they hear in the presence of the D&HH. That includes auditory flatulence (Not really necessary in my opinion as their olfactory system is still intact).

Until next time, remember that kindness is the language the Deaf can hear and the blind can see.

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Avoid Supermarket Ploys to Eat Healthier

Elizabeth Smith, EMT-B | From the January 2008 Issue | Wednesday, April 24, 2013

Good nutrition starts in the grocery store, because having healthy ingredients on hand is the first step for preparing healthy meals. For a lot of people, the amount of food on grocery store shelves can be overwhelming. The average supermarket stocks thousands of items, and there are more new items available each day. Products are strategically advertised and placed to catch our eyes and convince us that we need them. Grocery stores intend to sell food, after all. Information on labels can be confusing and misleading, causing us to buy “healthy” products that we think are good for us but aren’t healthy at all. All of this, combined with personal habits, lack of knowledge and lack of time, can mean walking out of the store $50 lighter with nothing to show for it but a box of soy cookies and 15 packs of microwavable noodles.

Product Placement
One of the best tactics for being an informed consumer is to understand the anatomy of the grocery store. It’s most important to know the healthiest foods are on the perimeter. In the vast majority of markets, the produce section, dairy refrigerator, meat and fish counters, and bakery with fresh-baked breads all lie on the outer edges of the store. The middle of the store contains mainly processed, pre-packaged convenience foods. These foods are high in sodium and often low in nutritional value, so you should eat them sparingly. This layout is intentional. We have to walk past all these money-making processed foods to get to the back of the store for the staples we actually need.

Another strategy for being a healthier consumer is to be aware of the way items are placed on the shelf. The area right at the customer’s eye level is considered prime space. Stores actually charge more to place products there, so those shelves tend to carry national brands and bestselling products. The lower shelves, set in the line of sight of a child, usually carry products with bright colors and lots of sugar, meant to appeal to children who are at the right height to reach out and grab them. The very bottom shelf tends to have larger items, often bulk, that can be comparable to and more affordable than items placed more visibly. So if we head in without a plan, we’re more likely to buy the items that are most easily seen and most brightly colored (especially if there’s a child helping with the shopping), rather than those that are the best price or most healthful.

Shop with a Strategy
The soundest strategy for avoiding these marketing tactics is to start your shopping adventure armed with a plan. Before heading to the store, make a list of the meals you want to prepare for the week. For each day, plan out breakfast, lunch and dinner. This doesn’t need to be fancy. You may eat cereal for breakfast every day, so that’s all you need to write in your menu.
From your menu, make a shopping list. Include each item you will need for your planned meals and its quantity. For example, if you’re making grilled chicken breast for two, you would write: “Boneless, skinless chicken breast (2).” This tells you exactly what you need to pick up off the shelf (see a sample meal plan at right and a sample shopping list below). As you become more familiar with your grocery store, you can arrange your list in order of the store layout, making it easier to avoid retracing your steps and reducing the amount of time you spend shopping.

When you’re ready to go shopping, make sure to eat a small snack or meal before you leave. Going to the store hungry drastically increases the chances you will buy junk food. Once you arrive, stick to your list. Remember the tactics vendors use to convince you to spend more, and don’t buy into them. Buy only what you need, and you will save money while avoiding the temptation brought by having a cabinet full of sandwich cookies and potato chips.

Produce
Strawberries (1 pint)
Green peppers (2)
Onions (2)
Romaine lettuce (2 heads)
Asparagus (1 bunch)
Button mushrooms (1 package)
Green beans (3 cups)
Idaho potatoes (1 bag)

Refrigerated
Eggs (1 dozen large)
Skim milk (1 gallon)
Low fat shredded cheddar cheese (1 package)
Low fat shredded mozzarella cheese (1 package)
Fat-free sour cream (1 container)
Spray butter
Sliced turkey breast (1 package)
Chicken breasts (4)
Pork chops (2)
Lean ground beef (1 pound)

Frozen
Frozen vegetables (1 package)
Black bean burgers (1 box)

Prepared
Frosted Mini Wheats (1 box)
Whole wheat bread (1 loaf)
Whole wheat spaghetti (1 box)
Marinara sauce (1 jar)
Pizza sauce (1 jar)
Prepared pizza crust (1)
Breadcrumbs (1 container)
Taco shells (1 box)
Salsa (1 jar)
Brown rice (1 box)
Whole wheat tortilla chips (1 bag)

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Preventing Violence Against EMS and First Responders

Michael J. Ward, BS, MGA, MIFireE, NREMT | From the March 2013 Issue | Friday, April 5, 2013

The Newtown (Conn.) school shooting and Webster (N.Y.) ambush of firefighters provide increased awareness of violence against emergency responders. East Hartford (Conn.) Fire Chief John Oates, writing for the National Fallen Fire Fighters (NFFF), has provided nine questions responders should ask:

1. Do you use risk/benefit analysis for every call?
2. Do you have an effective relationship at all levels with the law enforcement agencies in your community?
3. How good is the information you get from your dispatcher?
4. Do you allow members to “first respond” directly to the scene?
5. Does your law enforcement agency use an incident management system?
6. When responding to a potentially violent incident, do you seek out a law enforcement officer when you arrive?
7. Have you told your fire officers/personnel that it’s OK to leave the scene if things start to turn bad?
8. Is there a point at which you don’t respond or limit your response to violent incidents?
9. Is your uniform easily mistaken for law enforcement?

These questions came from a March 2012 focus group of 35 participants representing 29 organizations. The NFFF-commissioned report from this group, “Firefighter Life Safety Initiative 12 Final Report: National protocols for response to violent incidents should be developed and championed,” is part of a resource package covering 16 Firefighter Life Safety Initiatives of the Everyone Goes Home program.

Preventing Line-of-Duty Injury
Everyone Goes Home is a national program by the National Fallen Firefighters Foundation to prevent line-of-duty deaths and injuries. In March 2004, a Firefighter Life Safety Summit was held in Tampa, Fla., to address the cultural, philosophical, technical and procedural problems that affected safety within the fire service. The most important domains were identified, resulting in 16 Firefighter Life Safety Initiatives. Everyone Goes Home started as a way of implementing initiatives at the local level.

NFFF asked subject matter experts to develop a white paper for each initiative. Chief Oates provided the Initiative 12 report. The Novato, Calif., 2007 summit developed actionable objectives to support each of the Firefighter Life Safety Initiatives.

Noting that there was, “an absence of response protocols for violent incidents in many fire departments” a focus group met in Anne Arundel County, Md., in 2012 to develop an expanded report for Initiative 12, including the nine questions.

There’s no enforcement authority or funding to implement the Firefighter Life Safety Initiatives. Some feel that more effort should be directed against those who assault responders.

‘Paramedics Are Not Punching Bags’
New South Wales, Australia, ambulance service acting Commissioner Mike Willis announced a zero-tolerance policy toward violence against EMS personnel, noting on the agency’s website that there were six assaults against paramedics in early December.

There’s a perception that sanctions against those who assault EMS personnel are inadequate. In Illinois it’s a felony to assault a first responder; however, Chicago paramedics claimed, in a WLS-TV ABC News 7 report, that those who assault them get trivial punishment.

One technique that has been used is to fill a courtroom with emergency responders in uniform. In January, the New York Post reported that two dozen EMS workers filled a Manhattan courtroom to support their colleague who was allegedly choked by a drunken assistant district attorney.

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The Final EMS Call of Cody Medley & Tim McCormick

Guy H. Haskell | | Tuesday, April 2, 2013

I woke up for my shift on Medic 15 one Saturday morning in late February and rolled over to check the phone for messages. I was in no way prepared for the message I received from Indianapolis EMS Command.

Several hours earlier, at 3:37 a.m., Medic 50 was hit downtown, driving non-emergent with no patient on board as it crossed the intersection of St. Claire and Senate under a flashing yellow light. A two-door sedan blew a flashing red light and struck the Type III ambulance in front of the left rear wheels. Medic 50 flipped on its right side and slid down Senate until it was stopped when the cab was crushed against a parked car. Tim McCormick, 24 year-old EMT and private with Indianapolis EMS, was driving. Cody Medley, 22 year-old paramedic and IEMS specialist, was in the right seat. Both sustained fatal head injuries. Tim died at the scene. Cody died a day later in the ICU.

I had worked with Cody several times when he didn’t have a partner on Medic 18. He was young and brash and enthusiastic and always a pleasure to work with. I recognized Tim but hadn’t had the chance to work with him. Since that awful day, I have learned much about them both, and what remarkable young men they were. In the weeks since the crash, the public has had a chance to learn about Cody and Tim.

Others who knew them well have written about these two wonderful young men, their lives and their contributions. What I would like to do is give one paramedic’s thoughts on this past bittersweet week

In January 2011, I wrote a column titled “Happy Birthday Indianapolis Emergency Medical Services,” about the merger of Wishard Ambulance, the county hospital based EMS, and Indianapolis Fire Department EMS. On Dec. 26, 2010, they became one third service alongside police and fire. I wrote then that “EMS is the bastard stepchild of public safety. The Johnny-come-lately. The poor cousin. There isn’t an EMT in the country who would disagree. The only question is, how do we change our status?” One model, the one I preferred, was the one taken by the merger—the third-service model.

This past week, when Tim and Cody died, we were a little over two years into the merger. There have been ups and downs, advances and setbacks, some turf battles and bruised egos on both sides. These things are inevitable. But there has been real progress, not least of all the welcoming of IEMS into IAFF local 416.

I drove to work on Saturday morning very sad and not knowing what to expect. When I arrived at headquarters to begin my shift the parking lot was packed with command vehicles and news vans. I worked shifts on Saturday, Sunday, and Wednesday, and I am writing this on duty on Medic 54 a week later at a table on the apparatus floor behind Engine 54. I was able to watch the week unfold, and along with the sadness, each day brought me a sense of hope and wonder.

I admit that I was a cynic Saturday morning. How much would anyone outside our service really care about two young EMTs, only a couple of years on the job, dying in a traffic accident?

I was a paramedic in Worcester, Mass. in on the night of Dec. 3, 1999, when the Cold Storage Warehouse Fire claimed six firefighters in a black maze of death. I witnessed thousands of firefighters from all over North America and beyond come to embrace us in our sorrow. I was on duty in the EMS tent when thousands filed passed as local crews sifted through the rubble to find their brothers’ remains.  I saw the universal outpouring of grief and support when my hometown was devastated on Sept. 11, 2001, when 343 firefighters and paramedics and 59 police officers perished in the rubble. So how much would anybody care about two young EMTs?

I was wrong to be cynical. Every day I witnessed a flood of caring for those two young men and their families and their colleagues so far beyond what I had expected it was like a dream. Weeping police officers hugging in the street; tough inner city firefighters choking back sobs at a debriefing at the union hall; intense and caring media coverage; a stranger knocking on the window of Medic 21 on Wednesday night as I waited for my partner in front of Kroger to share his grief and offer his support and his thanks.

The city of Indianapolis, the Indianapolis Fire Department and the Indianapolis Metropolitan Police Department couldn’t have done more to honor Tim and Cody and support us in our sadness. The memorial for the boys on Wednesday filled the Butler University auditorium. IFD took on most duties to free IEMS to grieve. The Indianapolis Firefighters Emerald Society led the processional. The hall was filled with Class A Uniforms and brass from all the services; the love and support was palpable. The State Police provided an honor guard for the salute, and a bugler who played taps as clearly and as sweetly as I have ever heard it played. The Mayor and Council Chair and US Senator and others spoke words of kindness and appreciation. County Dispatch sent out the Last Call. Representatives from all over the State and beyond came to support us. When Tim’s body was returned to New York City to be interned in his home borough of Staten Island, the FDNY treated him as their own. The Fire Commissioner was there; the FDNY Emerald Society Pipes and Drums were there; the honor guards were there.

Never, never in my 30 years in EMS have I felt more honored, more appreciated. Thank you, brothers and sisters.

Cody and Tim,

I believe it was because of the force of your personalities, because of your caring and enthusiasm for this thankless work, because there were few that could know you and not like you, not love you, that we received the degree of support we did. You have brought us together; you have united us by your sacrifice; in blood you have formed a bond between us that might otherwise never have been forged. Thank you. You will not be forgotten.

All my love,
Guy

“3 ALERT TONES
ATTENTION ALL STATIONS and ALL PERSONELL.
EFFECTIVE February 20, 2013 INDIANAPOLIS EMS MEDIC 50, PARAMEDIC CODY MEDLEY and EMT TIM McCORMICK HAVE MADE THEIR FINAL CALL AND ARE NOW OUT OF SERVICE. THEY WILL BE MISSED BUT NEVER FORGOTTEN.”

Central Dispatch call to all units, 12 p.m., Feb. 20, 2013
Links:
Memorial t-shirts and hoodies—proceeds to Indianapolis Fire Rescue House: http://www.indyfrh.org/store/products/memorial-shirts-hoodies/
facebook: http://www.facebook.com/IndianapolisEMS
Indianapolis EMS: http://indianapolisems.org/
FDNY tribute on Staten Island: http://photos.silive.com/4499/gallery/staten_island_funeral_is_held_for_fallen_indianapolis_ems_private_timothy_c_mccormick/index.html
Memorial Program: http://indianapolisems.org/wp-content/uploads/2010/12/McCormickMedley-Program-Pgs.pdf 

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Ohio Medics Carrying Guns for Personal Protection

Richard Huff, NREMT-B | From the January 2008 Issue | Thursday, May 30, 2013

In a profession where staffers are known to pack extra equipment into their belt loops, a few EMS and fire providers in Bethel Township, Ohio, are adding just a little more kick—firearms.

For about a year, the Bethel Township Fire and EMS Department has allowed first responders to carry concealed weapons on emergency calls as a way to protect themselves in an area where having law enforcement respond to calls in a timely manner when needed can be a challenge due to reduced staffing.

The idea to let first responders carry weapons was hatched after budget cuts reduced the number of available officers in the response area served by the department, says Bethel Township Fire and EMS Department Chief Jacob King.

“Law enforcement is a huge piece of this,” King says. “When you’re lacking a lot of assistance, you have to change the way you do business.”

King’s department handles 2,100 calls a year, some 1,600 of them for medical emergencies. King says there have been times when his staff hasn’t felt a scene was safe and the delay in getting law enforcement support has made the wait to render aid too long.

“The ones that do carry [guns] feel safer,” King says, adding that just a few members participate in the program.

Under the Bethel Township program, staff members who hold concealed carry gun permits through the state of Ohio may carry them while on duty. Before doing so, King says, they’re provided significant training on when and how to use them. So far, he says, not one provider has used their weapon in the line of duty.

Violent Incidents
Word of the Bethel Township Fire Department gun program has surfaced at a time when there have been intense conversations within the field on EMS staff safety and what may be done about it. Although first responder safety is always an issue, concerns escalated to a heightened level of awareness in December when a man in Webster, N.Y., set fire to his home and then shot at firefighters responding to the blaze. Four were shot and two were killed in the ambush.

Then in April 2013, a man in Gwinnett County, Ga., called in a medical emergency. When firefighters responded to the house, he took them hostage. Police SWAT team members eventually gained access to the home and killed the man. The firefighters later said the man admitted to them he called for medical help because he didn’t think they would be armed.

Even before those incidents, there had been an increased focus on responder safety. Indeed, street safety classes teach EMS responders how to react in unsafe conditions. And more agencies are getting bulletproof vests for their employees. For instance, in March, Dorchester County, Md., officials voted to allow the county’s emergency services department to shop for bulletproof vests after a crew showed up for a seizure call only to find out the seizure was secondary to a gunshot wound and the scene was unsecured when the team got there.

The decision to carry guns is a personal one for every department, says King, and it may not be right for every situation. In the case of Bethel Township, they’re simply providing the same rights that every other Ohio resident has to carry a concealed gun. “And in no way, shape or form do we ever want to inflict harm against any of our citizens,” adds King.

Likewise, King says, the decision to let staff carry their own weapons isn’t an effort for them to replace law enforcement. Instead, it’s a way for his staff to feel comfortable helping people where they might not otherwise feel safe.

“We saw several calls that would require immediate [medical] intervention to help save a person’s life and we would just sit and wait,” King says.

“They didn’t have the opportunity to even do something,” he adds. “When I don’t have the opportunity to even try to save someone’s life—that gets to me more than when I make a mistake.”

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Recommendations for Creating an EMS Culture of Safety

Teresa McCallion, EMT-B | | Friday, May 3, 2013

The following article is an EMS Insider exclusive from the May 2013 issue. EMS Insider, the premier publication for EMS managers, supervisors, chiefs and medical directors, is a must-have resource for the critical, accurate information EMS leaders need. The monthly publication offers quality investigative reporting, exclusive articles, management tips and the very latest news on legislative issues, grants, current trends and controversies. For more about how to become an Insider, click here.

Note: This is part one of a two-part article on strategies for creating an EMS culture of safety, based on the EMS Culture of Safety Project.

Designing safety measures for an inherently unsafe environment isn’t a new concept. Other industries, from aviation to transportation, have tackled the task. However, in the relatively young profession of EMS, implementing and enforcing safety measures has been a challenge. In part, the difficulty is attempting to change perceptions among EMS practitioners. Often, our view of ourselves as swashbuckling, yet resourceful (and charismatic) scallywags, doing whatever it takes to save lives, means that danger is a thrilling part of the job. “It’s a short distance from gods to pirates,” says Tom Judge, CCT-P, executive director of LifeFlight of Maine. Judge is a long time safety advocate and current member of the National Emergency Medical Services Advisory Council (NEMSAC).

For the past three years, 18 EMS leaders have been working on the National EMS Culture of Safety Project. The process involved collaboration and input from a variety of stakeholders both inside and outside the EMS community. A final draft was presented to NEMSAC at its December meeting. NEMSAC has provided feedback on the 97-page draft, which the committee will use to update the document. On May 15, they will submit the updated version to the National Highway Traffic Safety Administration (NHTSA), which will pass it through its internal clearance process. The final document is expected to be published in September.

Funding for the project was provided by NHTSA, with support from the Health Resources and Services Administration’s (HRSA) EMS for Children (EMSC) Program and the American College of Emergency Physicians (ACEP).

The primary objective, according to the EMS Culture of Safety chair Sabina Braithwaite, MD, MPH, FACEP, is to develop a strategy for a new EMS culture of safety within the profession that encompasses all aspects of EMS. “We don’t want something that sits on a shelf,” she says. It isn’t intended as a safety manual, addressing everyday operational details. Rather, it’s a high-level document that identifies six key elements meant to help move an EMS organization toward a culture of safety.

Judge praises the group for the thoroughness of their work. “If we fundamentally change the culture of safety—preventing harm to the public, the patient and better protecting our work force—then everyone has a role, even the person at the pointy end of the stick,” he says.

The EMS leaders involved in developing the strategy emphasize that serious changes to the practice of provider and patient safety won’t occur with the simple imposition of a new set of rules. “If we are going to reform the genetic code of what we do, there’s a whole element of culture that must change,” Judge says. “That change starts with a ‘trust culture,’ then a ‘reporting culture,’ a ‘learning culture,’ then this whole concept of ‘flexible culture.’ The final steps are ‘Just Culture’ and ‘generative culture.’” According to Judge, one of the most important insights he learned in the process is that a culture of safety is a loop, not a continuum.

The Culture of Safety group examined all aspects of provider and patient safety. They also considered the safety of the community by exploring ways to reduce ambulance crashes.

They encountered a number of difficulties, but none more significant than the lack of data on the extent of EMS-related injuries, illness, fatalities and adverse medical events. “Reporting requirements and mechanisms are inconsistent at best, making accurate research problematic,” they note in the report. A lack of standardization further complicates the assessment of available data.

Yet, it was the consensus of the EMS leaders involved in the project—plus the more than 20 stakeholder groups that contributed to the report, and the general EMS community that participated in the public comment process—that it would be unacceptable and irresponsible to withhold action until clear evidence could be assembled and assessed. Therefore, the recommendations of the EMS Culture of Safety project are based on science, best practices in other areas of healthcare, and trends both within and outside EMS.

A key issue in understanding the current state of the culture of safety, says Judge, is the low barrier to entry for EMS. It isn’t considered a profession, yet providers are responsible for conducting challenging tasks in a difficult environment under the umbrella of an ever-changing discipline. “In some ways, we do remarkably well,” Judge says. “It’s an incredibly complex endeavor, delivering mobile medicine, 24/7, in uncontrolled scenes under the worst of circumstances. The reality is that we’ve been more lucky than good.”

Judge acknowledges that not everyone will agree with the findings in the report, but he’s pragmatic. “This is going to be a journey,” Judge says. “If EMS is going to take this on, like any journey, there are going to be some people who don’t want to go.”

The reality is that the stakes are too high to fail. “The almost one million EMS professionals in the U.S.—and the hundreds of millions of citizens who expect and deserve functional, efficient, professional EMS to be there for every emergency and every disaster—are all depending on this endeavor to create a safer EMS system,” the report summary concludes.

Using Haddon’s matrix, the Culture of Safety project takes a unique approach to system safety. First, it examines the pre-event—what are the protective processes, design elements and strategies to improve safety prior to the 9-1-1 call? Next, what can be done during the actual response? Finally, how can we learn and improve systems safety design post event? The pre-event elements include education, safety standards, research and data.

EMS Education Initiatives
Education represents a significant opportunity in how the values and practical elements of a culture of safety are introduced and internalized. Whether initial programs or continuing education, safety must be fully integrated into each component of EMS education. “System safety principles need to be ingrained from the minute they walk through the door. Doing something safe is as important as doing something well,” Judge says.

The report writers warn not to expect quick acceptance. Cultural change, they state, will most likely be measured in generations.

Education initiatives include:

Incorporating leaders in safety education: The successful implementation of a safety culture hinges on buy-in from the top. Education efforts must include not just practitioners, but leaders, who will “own” EMS responder and patient safety. The report notes that EMS leaders are often promoted without much training in leadership skills or competencies. They recommend a more systematic approach that emphasizes safety and the concept of Just Culture.Identifying at-risk candidates early: Entities that teach EMS education should actively identify candidates who display at-risk behavior or have risk-seeking attitudes.Building clinical judgment: Changes in initial and ongoing education must move from a focus on technical skills to an emphasis on developing practitioners who are capable of critical thinking and judgment.Transitioning new employees: The report recognizes that newly hired EMS employees are often paired with field providers who intentionally or unintentionally “undo” responder- and patient-safety education. Improvements to education programs that provide better real-world scenarios and increased preparation and support for field training officers or mentors are offered as possible solutions. The report notes that the National EMS Management Association recently created the EMS Field Training and Evaluation Program, which seeks to standardize and improve an organization’s approach to this often overlooked element of education.Integrating safety into every component of EMS education: Safety must become an integral part of an organization’s culture. This includes everything from recruitment to continuing education.

EMS Safety Standards
The report recommends the establishment of an EMS Safety Resource Center (EMSSRC). The purpose is not to develop standards or duplicate work already being performed, but to act as a clearinghouse for existing work. The report notes that additional funding for research to develop and support standards is also needed.

The EMSSRC should, however, engage in a collaborative process to help prioritize the standards that need to be addressed and developed. Recommendations of safety topics, based on input from the EMS Culture of Safety Stakeholder Conference and public comments, included:

Physical fitness for practitioners;Shifts/fatigue;Violence categorization and reporting;Ambulance design;Safety competencies; andStandards for safety-related information communicated to responders, to include anticipated data available through next-generation 9-1-1.

EMS Safety Data System
The current lack of data on the frequency and nature of EMS responder injuries, adverse medical events and other provider and patient safety issues stymies attempts to assess their impact on EMS and the cost to patients and society, as well as attempts to identify and measure corrective action. To rectify the situation, the report recommends the establishment of a National EMS Responder and Patient Safety Data System. This system would serve several purposes.

First, it would provide for a “national, robust, well-designed, secure data system encompassing key information about EMS safety.” The data would be available to researchers, policymakers and individual EMS provider agencies.

Second, it would serve to help establish a much-needed set of standard data elements and definitions, allowing for comparisons and aggregate datasets.

The National EMS Responder and Patient Safety Data System wouldn’t develop its own database. Rather, it would serve as link to existing data systems. It would be established with consideration to previous work, such as the 2007 NHTSA-sponsored report, Feasibility for an EMS Workforce Safety and Health Surveillance System; the Near-Miss Reporting System, developed and maintained by the International Association of Fire Chiefs; and NEMSIS, among others. Previously untapped sources of data could include insurance carriers and the Agency for Healthcare Research and Quality.

Two distinct aspects of patient safety must be addressed: protections from physical harm and prevention of medical errors. With regard to provider safety, surveillance of both mental and physical health conditions that may lead to negative outcomes should be tracked and analyzed.

Of course, privacy and liability concerns remain a potential obstacle. The report recommends engaging legal expert advice on relevant issues.

Conclusion
Judge concedes that recommendations such as those found in the EMS Culture of Safety report can be seen as regulations. The specter of regulations often frightens people.

However, he notes that it’s possible to implement safety standards without harming an industry. For example, he states that when we board a plane, we and our fellow passengers have an expectation that we’ll reach our destination safely. “Commercial aviation is the most regulated, open industry in the world. We don’t argue about regulation there,” he says.

The real fear is that the regulation will come from a place without domain expertise. “It’s always better to regulate ourselves,” he says.

It’s also helpful to remember what’s at stake. “We are still the only profession that gets to just walk into people’s lives and they trust that you are going to do the right thing,” Judge says. “We need to live up to those expectations.”

A copy of the draft report is available at www.emscultureofsafety.org.

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