Jun 2015

For More Information Circle 38 on Reader Service Card
HELLP SYNDROME p. 39
EMS RESPONSE TIMES p. 46
MIH SUMMIT REPORT p. 51

JUNE 2015 | VOL. 44, NO. 6 $7.00
Visit us online at EMSWorld.com
The Education Issue

25 Conducting the Student Interview
28 How Technology Is Transforming
Continuing Education
32 Why Research Is Important in EMS
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ADVISORY BOARD
Peter Antevy, MD
CEO & Founder, Pediatric Emergency
Standards
Martin Hellman, MD, FAAP, FACEP

Attending Physician, Childrens Hospital of
Pittsburgh, Pittsburgh, PA
Tim Perkins, BS, EMT-P

EMS Systems Planner, Virginia Office of
EMS, Virginia DOH, Glen Allen, VA
James J. Augustine, MD, FACEP

Medical Advisor, Washington Township Fire
Department, Dayton, OH; Clinical Associate
Professor, Department of Emergency
Medicine, Wright State University, Dayton,
OH; Director of Clinical Operations,
Emergency Medicine Physicians, Canton, OH
Tim Hillier, Advanced Care Paramedic

Director of Professional Development, M.D.
Ambulance, Saskatoon, SK Canada
Carl J. Post, PhD

EMS Consultant, Lawrenceville, NJ
C.T. Chuck Kearns, MBA, EMT-P

EMS Consultant
Raphael M. Barishansky, MPH, MS, CPM

Director, Office of Emergency Medical
Services, Conn. Dept. of Public Health
G. Christopher Kelly, JD
Attorney at Law, Atlanta, GA; Chief Legal
Officer, EMS Consultants, Ltd.
Eric Beck, DO, NREMT-P

Associate Chief Medical Officer, American
Medical Response
Skip Kirkwood, MS, JD, EMT-P, EFO, CMO

Director, Durham County (NC) EMS
Bernard Beckerman, MD, FACEP

Associate Professor, School of Health and
Behavioral Sciences, York College (CUNY),
Jamaica, NY
Sean M. Kivlehan, MD, MPH, NREMT-P

Emergency Medicine Resident
University of California - San Francisco
Tom Bouthillet, NREMT-P

Captain, Town of Hilton Head Island (SC) Fire
& Rescue Division
Kenneth Bouvier, NREMT-P
Deputy Chief of Operations, New Orleans
EMS; NAEMT President 20042006
Rob Lawrence, MCMI

Chief Operating Officer, Richmond (VA)
Ambulance Authority
Chris Cebollero, NREMT-P

Senior Partner, Cebollero & Associates, St
Louis, MO
Todd J. LeDuc, MS, CFO, CEM

Assistant Fire Chief, Broward Sheriff Fire
Rescue, Ft. Lauderdale, FL
Will Chapleau, EMT-P, RN, TNS

Director of Performance Improvement,
American College of Surgeons
Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P,
WEMT
Clinical Education Coordinator, VitaLink/
AirLink, Wilmington, NC; Lead Instructor,
Wilderness Medical Associates
Alan R. Cowen, MA, EMT-P
Deputy Fire Chief (ret.), Los Angeles City Fire
Department, CA
Thom Dick
EMS Educator, Brighton, CO
William E. Gandy, JD, LP
EMS Educator and Consultant, Tucson, AZ
Erik S. Gaull, NREMT-P, CEM, CPP
Master Firefighter/Paramedic, Cabin John
Park (MD) Volunteer Fire Department
Troy M. Hagen, MBA, NREMT-P
CEO, Care Ambulance, Orange, CA;
President, National EMS Management
Association
William S. Krost, MBA, NREMT-P

Adjunct Assistant Professor of Emergency
Medicine, The George Washington
University
Ken Lavelle, MD, FACEP, NREMT-P
Clinical Instructor and Attending Physician,
Thomas Jefferson University Hospital,
Philadelphia, PA
Elliot Carhart, EdD, RRT, NRP

Assistant Professor, Emergency Services
Program, Jefferson College of Health
Sciences, Roanoke, VA
Michael W. Dailey, MD
Assistant Professor, Dept. of Emergency
Medicine, Albany Medical College, NY
Lou Jordan
PIO, Fire Police Officer, Union Bridge (MD)
Fire Department
Mark D. Levine, MD, FACEP

Assistant Professor, Dept. of Emergency
Medicine, Washington University School of
Medicine; Medical Director, St. Louis (MO)
Fire Dept.
Tracey Loscar, NREMT-P
Training Supervisor, UMDNJ - University
Hospital EMS, Newark, NJ
Craig Manifold, DO
EMS Medical Director, San Antonio Fire
Department and San Antonio AirLIFE;
Assistant Professor, University of Texas
Health Science Center at San Antonio
Paul M. Maniscalco, MPA, EMT-P
Senior Research Scientist & Principal
Investigator, The George Washington
University Office of Homeland Security
Norman E. McSwain Jr., MD
Department of Surgery, Tulane University
School of Medicine, New Orleans, LA
Richard W. Patrick, MS, CFO, EMT-P, FF
Director, Medical First Responder
Coordination, Office of Health Affairs
Medical Readiness, U.S. DHS
Michael E. Poynter, EMT-P

Executive Director, Kentucky Board of
Emergency Medical Services
Vincent D. Robbins
President & CEO, MONOC, MonmouthOcean Hospital Service Corporation,
Neptune, NJ
Mike Rubin
Paramedic, Nashville, TN
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William F. Toon, EdD, NREMT-P
EMS Training Manager, Loudoun County (VA)
Fire, Rescue and Emergency Management;
Battalion Chief - Training (ret.), Johnson
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David Wampler, PhD, LP
Assistant Professor, Emergency Health
Sciences, University of Texas Health Science
Center, San Antonio, TX
Paul A. Werfel, MS, NREMT-P
Director, Paramedic Program, Clinical Asst.
Professor of Health Science, School of
Health Technology & Management, Asst.
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Dept. of Emergency Medicine, Health
Science Center, Stony Brook University, NY
Katherine West, BSN, MSEd, CIC
Infection-Control Consultant, Infection
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Gerald C. Wydro, MD, FAAEM
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Contents
JUNE 2015
VOL. 44 | ISSUE 6
CO V ER R EP OR T: T HE EDUC AT ION ISSUE
25 Conducting the Student Interview

Its your best early chance to spot candidates not suited for EMS
By Mike Rubin
25
28 Best Practices in CE
How technology is changing the way we deliver continuing education
By the CECBEMS Board of Directors
32 Why Research Is Important in EMS

We need an evidence base, and you can help develop it
28
Richmond Ambulance Authority
By Mario J. Weber, JD, MPA, NRP, & Michael Gerber, MPH, NRP
COLUMNS
F E AT UR E S
15 CASE REVIEW
Severe Heat Illness
46 Should Response Time Be a

Performance Indicator?
By James J. Augustine, MD, FACEP
A survey of Pinnacle thought leaders opinions
20 GUEST EDITORIAL
Evaluating Patients
Decision-Making Capacity
51 MIH Summit 2015 Report
By Thom Dunn, NRP, PhD
Lessons learned from a fre-based MIH-CP

program
58 LIFE SUPPORT
Head of the Class
By Michael Gerber, MPH, NRP
By Mike Rubin, BS, NREMT-P
DEPARTMENTS
53 EMS State of the Sciences

Conference: Report from the
Gathering of Eagles Part 2
46
8
12
13
55
56
By Ed Mund
CE A R T ICL E
EMS World Online

From the Editor
EMS News Network
Advertiser Index
Classifed Ads
ON THE COVER
Photo in tablet courtesy of
Richmond Ambulance Authority,
www.raaems.org.
39 HELLP Syndrome
How to recognize and treat this
life-threatening complication of
pregnancy
39
EMS World ISSN 1946-9365 (print) and ISSN 1946-4967 (online) is
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By Scott R. Snyder, BS, NREMT-P, Sean M. Kivlehan, MD, MPH,

NREMT-P, & Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT
U.S.A. POSTMASTER: Please send change of address to EMS World,

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The views and opinions in the articles herein are not to be taken as
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official expressions of the publishers, unless so stated. The publishers do

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storage and retrieval system without written permission from EMS World.
SEPTEMBER 16, 2015 LAS VEGAS, NV
Hosted by NAEMTs PHTLS Committee and EMS World Expo
It will change the way you practice.

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Attend the World Trauma Symposium to learn how trauma care will be
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This 1-day educational event, developed by the creators of PHTLS and held
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This years symposium will examine several topics, including:
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Patient Immobilization: The Death of the Backboard
Trauma Research: What Does the Evidence Say?
Sport Injuries: Concussion Management
Register today to gain access to the brightest minds in trauma research.

Visit WorldTraumaSymposium.com, sign up by Aug. 14 and save $50. Enter code: EARLYREG
EMS WORLD ONLINE
facebook.com/emsworldfans
twitter.com/emsworldnews
www.linkedin.com/
groups?gid=1853412
FE ATURES
Like any business,
every EMS provider
who charges user fees
has some percentage
of customers who are
unable to pay due to
fnancial hardship. Most
just write the unpaid
fees of as bad debts;
Life EMS Ambulance
converts some of these unpaid fees into volunteer assistance at local
nonproft groups. Read more at EMSWorld.com/12072080.
GUEST EDITORIAL: ARE YOU A MICROMANAGER?
The term micromanagement often refers

to inappropriately close observation
and control of a subordinates work by
a manager. But can micromanagement
ever be a good thing? Is there a method
of micromanaging where managers can
manage from a distance and get more
involved when necessary? In this editorial, Raphael Barishansky outlines
how managers can use micromanagement to create a more productive
workplace. Read more at EMSWorld.com/12072862.
EXCLUSIVE: REPORT FROM

EMS WORLD EXPO
At last years EMS
World Expo, U.K.
PART 2:
doctor Linda Dykes
Clinical topics
and paramedic
A taster of the 2014
Alison Woodyatt
compiled summaries
from several key
sessions in the core
program, creating
an EMS World Expo
magazine.
The publication
is part of a series of
reports from several
international EMS
conferences. To read
more, see www.scribd.com/BangorED.
As part of the countdown to this years EMS World
Expo, scheduled for September 1519 in Las Vegas, NV,
we will be sharing several of the write-ups with our
EMSWorld.com readers.
See EMSWorld.com/12072867.
Another #FOAMEd production by
A totally unofficial report by

Alison Woodyatt (Paramedic, Welsh Ambulance)
& Dr Linda Dykes (Consultant in EM, Wales, UK)
Nov 11-13 2014
NASHVILLE
Photo courtesy EMS World
AMBULANCE SERVICES NON-PAYING CUSTOMERS TO

WORK OFF DEBT AS VOLUNTEERS
PLUS speakers report

by Rommie Duckworth
Update on surgical airways

Strangulation in domestic violence
Obstetric emergencies for EMS
Body piercings: implications for EMS
Agitated patients & Suicide intervention for EMS
Extrication: field trauma care at MVCs
Farm trauma
Edited & designed by Dr Linda Dykes
v1.0 9 Jan 2015
www.mountainmedicine.co.uk
PODC A S TS
EMS SQUADCAST: THE FUTURE OF
EMS
NEW
Host Tim Perkins chats with EMS educators

Dan Limmer and Joe Mistovich about changes
on the EMS horizon in regard to clinical
practice, product development and EMS
education. See EMSWorld.com/12072810.
I AM SO PROUD TO BE PART OF EMS AS

WE EVOLVE INTO THIS EVIDENCE-BASED
PRACTICE OF TREATING PATIENTS.
OF THE MONTH
Joe Mistovich, MEd, NREMT-P

Both Dan and Joe are featured
speakers at this years EMS World
Expo, scheduled for September
1519 in Las Vegas, NV. They will
be presenting two workshops
and several core program
sessions. Register today at
EMSWorldExpo.com.
MOULAGE
SPONSORED BY:
Bobbie Merica continues her guide to

simulating injuries and illnesses through
efective use of moulage. This month: blood.
See EMSWorld.com/12072811.
CALL FOR ENTRIES!
AWARD RECIPIENTS
RECEIVE
The nomination period is

now open for the National
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established by EMS World
and the National Association
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Technicians (NAEMT)
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$1,000;
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Meeting in Las Vegas,
NV, Sept. 1519
Go to EMSWorld.com/awards
to nominate your agency
or a colleague in the
following categories:
NOMINATION
DEADLINE:
JUNE 15, 2015
DICK FERNEAU
Recognizes outstanding
performance by a paid
EMS service.
sponsored by
ZOLL Volunteer EMS

Service of the Year
Recognizes outstanding
performance by a
volunteer EMS service.
sponsored by
THE YEA
NAEMT/Nasco
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Recognizes a paramedic
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THE YEA
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NAEMT/Braun Industries NAEMT/Jones & Bartlett NAEMT Military Medic

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demonstrates excellence Presented to an educator
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SEPTEMBER 1519, 2015 LAS VEGAS, NV
EMS World
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EMS World Expo sets the standard in EMS education,
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At EMS World Expo:
Learn about emerging
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FROM THE EDITOR
By Nancy Perry
Whats
on
the
Horizon?
Theres never been a more exciting time to be in EMS
An investment in knowledge
pays the best interest.
Benjamin Franklin
THIS MONTH I CELEBRATE MY 20TH ANNIVERSARY
working at EMS World. Having spent the past two decades
covering advances in prehospital practice, I dont think
theres been a more exciting time to be in EMS than right
now.
As authors Mario Weber and Michael Gerber report
in this issue, evidence-based practice is gaining traction
throughout EMS, as we transition to the use of high-quality evidencerather than consensus or expert opinion
as the basis for our clinical guidelines (see Why Research
Is Important in EMS on page 32). At the same time, we
are casting a critical eye over every aspect of EMS operations. Read Should Response Time Be a Performance
Indicator? on page 46 to find out what some of the

leading voices in EMS think about how we measure the
effectiveness and efficacy of EMS response.
Anyone eager to know whats next on the EMS horizon
should consider attending EMS World Expo 2015, scheduled for September 1519 in Las Vegas, NV.
At the largest EMS conference in North America, subject matter experts and leading manufacturers will gather
to discuss emerging trends in clinical care, review stateof-the-art technologies improving patient outcomes, and
showcase the products and services that will transform
your operations. This year we have added an MIH-CP
educational track that runs throughout the conference,
acknowledging the importance of numerous programs
across the country changing the way we deliver care.
Register today at EMSWorldExpo.com and find out
what the next 20 years hold for EMS. It will be an investment you wont regret.
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NEWS NETWORK By Christopher Kelly
One Ambulance Service, Four Hospitals Settle Fraud Case

The U.S. Attorneys office in Jacksonville,
FL, announced a healthcare fraud settlement in March that involved two ambulance
service suppliers and four hospitals.
The case was based on whistleblower
lawsuits filed in June 2011 and August 2014
in federal court by a former employee of
both of the ambulance services.
The settlement was reached in March
2015 with all defendants except for one of
the ambulance service suppliers who denies
the allegations. The U.S. Attorney has said
they will pursue the case against the one
ambulance company that has not settled.
The lawsuit alleges that both of the ambulance services altered patient care reports to
meet medical necessity and one required
crews to falsify information such as pulse ox
and EKG readings, while the other ordered
EMTs to omit all positive findings that would
prevent trips from being reimbursable.
The hospitals are accused of falsifying

patient conditions on physicians certification statements (PCS forms) in order to get
patients transported by ambulance who
could have traveled by other means.
While this is certainly not the first time
an ambulance service has been accused of
fraud, this is the first time I am aware of that
the government has pursued the PCS issue
against the person or entity who signed it.
This should give pause to hospitals or physicians who routinely misuse EMS by ordering
discharge transport by ambulance when it is
not medically necessary. However, this may
also cause them to refuse to sign even when
transport is justified due to the potential
liability created by signing the PCS.
For more information or to see copies of
the actual lawsuits, go to www.news4jax.
com/news/ambulance-fraud-lawsuits-name4-area-hospitals/31928530.
Some of the details of this settlement have

now been released. The hospitals are paying
the vast majority of the settlement amount.
Out of the total settlement of $7.5 million,
the four hospitals are paying $6.25 million.
The one ambulance service has agreed to
pay back $1.25 million. The U.S. Attorneys
office has stated that they have developed
a strategy for going after the hospitals even
though they do not directly benefit financially from the ambulance reimbursement.
Of course, this new position from the U.S.
Attorneys office may have a chilling impact
on hospitals willingness to sign PCS forms
nationwide.
Christopher Kelly is a lawyer who focuses on
regulatory healthcare law as it relates to the EMS and
ambulance industry. This article is not intended as
legal advice. For more information or questions, he
can be reached for a free initial consultation at EMS
Consultants, Ltd., 800/342-5460 or e-mail ckelly@
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EMSWORLD.com | JUNE 2015
13
NEWS NETWORK
By Katherine West, RN, BSN, MSEd
This short excerpt is from an expanded article available online at EMSWorld.com/12072772.
Measles Updates
In the year 2000, measles was declared eliminated in the United
States. Now, unfortunately, in 201415 it is back.
The most recent outbreak to make the news began from
December 28, 2014, to February 13, 2015. This outbreak appears to
have been started by a traveler who acquired the disease overseas
and then visited Disneyland in California, resulting in approximately
114 cases in seven states (California, Colorado, Nebraska, Utah,
Oregon, Washington and Arizona). By February 27 the numbers
had increased to 170 cases in 17 states and the District of Columbia.
About 125 cases are related to exposure at Disneyland. Outbreaks
in Illinois, Nevada and Washington are not related to the Disneyland
outbreak.
Your Best Protection

If not already protected by having had the disease, get vaccinated.
All fire/EMS personnel need to obtain their vaccine records and
health history records so they can be reviewed to ascertain who
is in need of vaccine for pre-exposure protection. Vaccination for
all healthcare providers is recommended by the CDC and that is
being enforced by OSHA. Also, the need for vaccine history and
the vaccination of unprotected personnel is addressed in the NFPA
Standard 1581 (Infection Control).

All employers of healthcare providers
are required to offer the vaccines free
of charge to employees. At this time, Katherine West is a
featured speaker at
employees and volunteers are permitted EMS World Expo, Sept.
to decline but must sign a declination 1519 in Las Vegas.
form. Declination forms are important Visit EMSWorldExpo.com.
as they document that the employer has
made the offer to vaccinate.
The vaccine is safe and effective. After only one dose of vaccine,
a person has a 93% level of protection. This is a two-dose series
vaccine and the doses should be administered at least 28 days
apart. Two doses yield a 99% protective level.
The vaccine administered today is a live-virus vaccine and is
combined with vaccines for mumps and rubella (MMR, or measles,
mumps, rubella). As this is a live-virus vaccine, women of childbearing age are advised not to become pregnant for four weeks after
each dose of vaccine.
Katherine West, RN, BSN, MSEd, has been working in the field of infection control
since 1975. She is an infection control consultant for Infection Control/Emerging
Concepts in VA.
14
CASE REVIEW
By James J. Augustine, MD, FACEP
Severe Heat Illness
Whats the key to recognizing a patient in danger?
ABOUT THE
AUTHOR
James J. Augustine,
MD, FACEP, is an
emergency physician
and the director of
clinical operations
at EMP in Canton,
OH. He serves on
the clinical faculty in
the Department of
Emergency Medicine
at Wright State
University; as an EMS
medical director for
fire-based systems in
Atlanta, GA; Naples,
FL; and Dayton, OH;
and on the EMS World
Editorial Advisory
Board. Contact him at
jaugustine@emp.com.
Copyright granted for this

article for department use
only up to 20 copies.
THE ATTACK ONE CREW is called to stand by for

a session at the departments training academy. The
day started off like most spring days, with a cool
morning and some fog, but about an hour before
the training was to begin, the fog dissipated and
temperatures warmed.
The session is a multipurpose one: The department is training on new ladder trucks, a new training tower and self-contained breathing apparatus
recently purchased for the agency. The training
will involve climbing evolutions and work inside the
tower. Multiple crews will go through their paces at
the same time, and fresh crews will arrive every two
hours to complete the rotations.
The senior members of the Attack One crew are
to provide training to junior department colleagues
during this session. The crew is responsible for any
injuries that occur and for establishing and maintaining a formal incident rehabilitation program. The
paramedic member of the Attack One crew is designated as rehab command and will be responsible for
the surveillance and rehabilitation functions.
The rehab area is placed close to the training
tower. It is initially set up in a sunny area of the training grounds, but soon the crew notices that temperatures are climbing and higher than predicted for
the day. They move the rehab area into some shade
and ask for cooling equipment to be brought from
the storage area where it spent the winter.
The rehab area is initially pretty quiet; the injuries
are mostly minor lacerations from the sharp edges of
the new equipment. But then some of the firefighters begin to get very warm and come in for cooling
and fluids.
One of the trainees notes the screening process
seems to rely on something other than traditional
teaching on heat-related illnesses: Ive noticed our
firefighters have all come in with cramping. Some
have really red skin, some are pale, and some have
normal-looking skin. That doesnt seem to predict
whos the sickest.
Thats correct, and youll see this take place the
rest of the afternoon, the paramedic responds.
Many of our members get really bright red skin as
they work. Some get cramps. Mental status change
is our key symptom. If someone isnt thinking clearly
Initial Assessment
A 45-year-old male, confused and warm to
the touch. He was initially reported to be
unresponsive but has been speaking since he
was removed from the training building.
PRIMARY SURVEY
AIRWAY: Open.
BREATHING: Uncompromised.
CIRCULATION: Poor capillary refill.
DISABILITY: Speaking inappropriately, not
oriented to time or place.
EXPOSURE OF OTHER MAJOR PROBLEMS:
Skin blotched, warm to touch on the head, but
extremities cool.
VITAL SIGNS
TIME
HR
BP
RR
PULSE
OX.
1240
130
100/palp.
28
94%
1246
136
104/palp.
28
95%
1253
142
96/palp.
24
92%
SECONDARY ASSESSMENT, APPROPRIATE

TO PRESENTING CONDITION
HEAD: No trauma.
NECK: No trauma or tenderness.
CHEST: Breathing rate increased, clear breath
sounds.
ABDOMEN: Not tender. Patient is nauseated.
EXTREMITIES: Moves all four, distal pulses
palpable. Skin becomes more blotched.
NEURO: No focal neurologic findings. Moves all
four extremities.
AMPLE ASSESSMENT
ALLERGIES: None.
MEDICATIONS: None known.
PAST MEDICAL HISTORY: Negative.
LAST INTAKE: Breakfast at 0700.
EVENT: Altered mental status with likely severe
heat illness.
15
CASE REVIEW
when they arrive, its a serious problem, and

wed head to a hospital. Most of the firefighters do fine with about 15 minutes of
cooling and some oral fluids. If they dont
act right and clear quickly, they go to the
hospital.
The Operation Changes

The training is going well, with members
hydrating between evolutions. But then
theres a call for help inside the training
building, and the crews scramble to drag
out a captain who has collapsed. They
bring him to the rehab area and remove his
equipment. Hed reportedly passed out in
the building but is now speaking, although
confused and disoriented. He complains of
being chilled.
The members of his crew exit the building and report their engine had a busy
morning, working a couple of car fires, and
they missed breakfast. The captain had
been outside most of the afternoon, and
no one could remember seeing him drink

anything. He started acting funny as they
were climbing ladders and moving through
the training building, and gave some unusual orders to his crew. He then slumped to
the ground.
The Attack One paramedic takes control
of the care. He notes the patients skin is
blotchy, and his pupils are dilated.
Get an ambulance here immediately,
he quickly directs his crew. Get a bunch
of cold, wet towels and put them on him.
Roll him on his side, because hell be vomiting soon.
Command, stop the training. We have
a medical emergency and will need to
dedicate the rehab crew to the care of this
patient. An ambulance is en route, and well
be making an emergency removal. When
a backup crew can replace us and reopen
the rehab area, the training can resume.
The paramedic asks for another member of the Attack One crew to conduct a
focused evaluation of the other members

of the captains engine crewif hes that
ill, theres a risk to them as well. The paramedic then dedicates himself to care of
THE PATIENT HAS A

RECTAL TEMPERATURE
OF 105F DESPITE
ABOUT 30 MINUTES OF
PREHOSPITAL
COOLING.
the captain and preparing him for rapid
transport. The crew performs continuous
surface cooling, provides supplemental
oxygen and keeps him on his side as he
begins vomiting.
The ambulance arrives, and the captain is
rapidly moved to it. The Attack One paramedic accompanies him to the hospital. IV
access cannot be obtained, and its difficult
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Serving our nations EMS practitioners
ers slowly. His career in the fire service is

complete.
to get a pulse oximetry reading due to poor

perfusion of the skin. The patients pulse
rate remains around 130, his blood pressure is 100/palpable, and his respiratory
rate is around 28 a minute. The three-lead
cardiac monitor shows a sinus tachycardia.
The patient becomes unresponsive except
to painful stimuli. The air conditioning is on
high, and the back of the ambulance gets
slippery due to water and ice being used
for cooling.
The paramedic directs the ambulance
to transport to the regional heart center
and calls ahead to notify the emergency
department.
Case Discussion
The most serious form of heat illness is
often referred to as heatstroke. The most
important symptom that differentiates
severe heat illness is an altered level of
consciousness. The risk factors for severe
heat illness are:
Poor physical fitness/excessive body
weight, and those who have had a previous heat-related illness;
Older age. Persons over 40, even those
in relatively good physical condition, have
an increased potential for heat illness;
Medications or street drugs. Many medications and a large number of illegal drugs
can impact the bodys temperature-regulating systems and hydration level;
Lack of heat acclimatization. This means
severe heat illnesses often happen in the
first few weeks or months after winter
Hospital Course
On arrival at the ED, the patient has a rectal temperature of 105F despite about 30
minutes of prehospital cooling. The cardiac bypass operating room is opened, and
he goes through that process. Hes then
placed in the intensive care unit and recov-
weather. By late August or September, most

of the United States is acclimatized to hot
weather, and severe heat illnesses are rare.
Severe heat illness occurs when the
bodys temperature-regulating and cooling mechanisms are not operating normally.
The victims metabolic systems can run out
of control, and the core temperature continues to rise. The earliest signs of heatstroke
are in the ability to think clearly. The victim
will often get confused or disoriented or act
in a way inappropriate for circumstances,
such as donning clothes because they feel
cold. Some patients get very agitated and
Learning Point
Incident rehabilitation is an important part
of training operations with heavy physical
activity. Altered mental status is the key
symptom for recognizing patients in serious trouble from a heat-related illness.
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CASE REVIEW
SEVERE HEAT ILLNESS WILL CAUSE

PERMANENT DISABILITY OR DEATH IF
EMERGENCY CARE DOES NOT BEGIN PROMPTLY.
violent, similar to a patient having an insulin
reaction. The skin temperature may not be
warm, and many heatstroke patients appear
pale or ashen. A few have the classic red,

hot and dry skin and are not sweating. A
victim may complain of cramps, throbbing
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headache, nausea, vomiting and dizziness.

In later stages the victim will be unconscious or seizing.
It is difficult to obtain an oral temperaure,
as the victim is typically breathing very fast,
may be vomiting and will have difficulty
holding a thermometer in a closed mouth.
The hospital will rely on a rectal temperature to get an accurate reading on heatstroke patients.
Severe heat illness will cause permanent
disability or death if emergency care does
not begin promptly. Aggressive internal
methods of cooling will be needed at a
hospital. The victim may be slightly dehydrated, but large volumes of IV fluids are
rarely needed and may be dangerous.
External cooling is typically not effective
by itself, but it needs to be started in the
field:
Get the victim to a sun-shaded location;
Remove whatever clothing you can while
maintaining modesty;
Put the victim on his/her side, as most
will vomit;
Cool the victim rapidly using anything
available. Spraying with cool water and a
fan is effective;
Use cold compresses (cold/iced towels
are most useful) to the forehead, axilla and
groin areas;
If available, immerse the victim in a pool
or tub of cool water or a cool shower;
Do not give the victim large volumes
of fluids to drink, as this will likely result in
vomiting;
If it does not delay transport, start an IV
and give a small bolus of fluids.
Incident Rehabilitation
NFPA 1584: Standard on the Rehabilitation
Process for Members During Emergency
Operations and Training Exercises was instituted in 2008, and the second revision will
be published shortly. The standard states,
Procedures shall be in place to ensure that
rehabilitation operations commence whenever emergency operations pose the risk of
members exceeding a safe level of physical
or mental endurance.
The standard calls for liberal application of rehabilitation services at working
incidents and training operations. This is
to be applied by organizations providing

rescue, fire suppression, emergency medical services, hazardous-materials mitigation,
special operations and other emergency
services, including public, military, private
and industrial fire departments.
NFPA 1584 is to be applied in a broad
range of circumstances, so discussions
need to include the leadership of local EMS
and fire support agencies. Many departments find it helpful to do this planning in
tandem with other regional fire and EMS
providers so programs have similar elements and consistency in applications,
training, equipment and documentation.
The program will need to include a process for implementing rehabilitation operations at all types of incidents and times of
day. Separate resources are needed for
cold-weather rehab. As demonstrated in
this case, a surveillance and rehab program is needed at training exercises and
for other physically demanding duties. This
will include screening and surveillance programs to protect candidates and department members taking part in these strenuous activities.
Many fire departments work with support
EMS agencies. These EMS personnel must
be trained and equipped to perform fire
rehabilitation services. Programs should
include training, equipment, methods of
deployment, collection of information,
documentation and integration with other
critical scene responsibilities. If EMS personnel are to establish and maintain the
rehab program, how will that be accomplished at incidents where there are civilian
victims? Who provides rehab if a firefighter
gets injured and needs to be transported to
a hospital? How will rehab crews be utilized
and rotated in prolonged incidents?
Some departments have invested in
equipment useful for personnel cooling.
This may include cooling systems, fans,
shades, drink dispensers, icemakers
and other equipment that increases the

effectiveness of the process. Fluid coolers
alone are not sufficient for victim cooling, and Gatorade showers for incident
and rehabilitation command officers are
rarely utilized.
James Augustine is a featured speaker at

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19
GUEST EDITORIAL
By Thom Dunn, NRP, PHD
Evaluating Patients DecisionMaking Capacity

Some may wish to decline needed careshould you allow it?
Jones and Bartlett Publishers. Courtesy of MIEMSS.
EMS IS CALLED to a local drinking establishment

for a report of a bar fight with injuries. After arriving
on scene and checking in with the police, the crew
is directed to a 22-year-old male standing outside,
holding a bloody bar towel to the upper left quadrant
of his abdomen. Ive been stabbed in the gut! he
shouts. The attending paramedic finds a strong radial
pulse of 124 and directs the man to start walking
toward the ambulance. Im not going to the hospital,
and you cant kidnap me! he shouts even louder. The
paramedic calls medical direction, which asks, Is he
sober and competent?
EMS providers are regularly challenged with ethical
issues during the course of their work. Ethical dilem-
20
mas are situations that present with no clear right

answer and where more than one course of action
can be defended.
In the case above, there is a patient with penetrating trauma to the abdomen. In any EMS system, this
is a priority patient. But wait: He is objecting to treatment and transport. The ethical dilemma is created
due to our value of patient autonomy and shared
decision-making between provider and patient.
However, many would argue this patient is at high risk
for a bad outcome if he doesnt seek medical care.
I started thinking about these issues long after I
started working in EMS in the 1980s. Im an active
paramedic field instructor for an urban EMS system,
but Im also a clinical psychologist in an

academic medical center. As a psychologist, I am regularly called upon to assess
the decision-making capacity of patients
who refuse lifesaving care.
After several years of this, I was invited
to sit on the hospitals ethics committee,
where many issues are similar to the case
above: Someone refuses care or cannot
voice their wishes, and others make decisions for them. What struck me most was
how many EMS providers face the same
ethical dilemmas as physicians, but without
the support often found in hospitals (such
as on-call specialists like psychologists,
an ethics committee, risk managers, legal
department, etc.). This article is intended
to help guide EMS providers through an
ethical dilemma they encounter often: the
patient who needs treatment but declines
help.
The Shared Decision-Making

Model
EMS providers and physicians share many
parallels. Both meet their patients and
ascertain a chief complaint, then form a
clinical impression after taking a history
and performing a physical exam and using
other diagnostics. Options are discussed,
and a treatment plan is decided upon. This
model, shared decision-making (SDM),
came about in the early 1990s and honors
the patients right to autonomy over their
own body.1 This is the bedrock of informed
consent. The patient is given options, risks
and benefits are explained, and the patient
makes an informed choice. Conflict arises
when the provider and patient are unable
to reach a decision together about the best
course of action, typically when the patient
decides differently than what the clinician
believes to be best.
EMS providers regularly meet patients
who decline ambulance transport. For
example, there are individuals who are
injured in motor vehicle collisions, but not
sufficiently that they believe they need prehospital care and transport. Similarly, diabetics who have become hypoglycemic and
recovered after the administration of glucose often decline transport. In most EMS
systems, the patient and provider complete
paperwork documenting the patients decision not to be transported by ambulance.

Often this paperwork documents the risks
to declining care and that the patient has
been informed of such risks in deciding
against transport.
Less common but far more risky are
the patients who would likely benefit
from transport and treatment who decide

against it. In some instances these patient
may be making decisions that will lead to
death or disability. Its a fine line for the
paramedic or EMT to walk: Respect the
patients right to autonomy to refuse care,
while knowing such a decision may lead
to that patients death. In these instances,
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21
GUEST EDITORIAL
most EMS systems require the EMT or paramedic to assess the patients capacity to
decline transport and make contact with
medical control. The case at the beginning
is an extreme one, but exploring it can help
frame how to approach such situations.
Evaluating Capacity
While the word competent is often used
when discussing decision-making ability,
such a term is typically reserved for use only
by judges making legal decisions.2 Our discussion concerns medical decision-making
ability (as opposed to the capacity to make
other decisions, such as financial ones). The
physicians question, Is he sober and competent? speaks directly to this. It means,
Are there features about this patient
that impair his ability to make decisions?
including intoxication. Its important that
EMS providers are able to evaluate medical decision-making capacity.
There are several different approaches to
assessing decision-making capacity. I am

partial to this one and use a modified version of it when working as a paramedic and
or assessing patients as a psychologist.3
1. Is the patient an adult without a guardian? In the prehospital arena, children may
not refuse transport. Some adults also
have guardians who make their decisions.
In these instances the EMS providers deal
with the patients parent or guardian.
2. Can the patient communicate a choice
about his or her care? For obvious reasons,
if the patient cannot communicate their
wishes, decisions have to be made by someone else. I also believe patients who refuse
to cooperate with an evaluation regarding
their decision-making capacity fall into this
category. By refusing to communicate with
me, these patients are deemed as lacking
decision-making capacity.
Steps 3 and 4 are incumbent on the
patient being able to process information. Inherent in these steps is whether the
patient is free from an altered mental status

and not under the influence of an intoxicating substance. I also worry about patients
with possible head injuries or other disease
processes known to impair cognition (such
I ALSO WORRY ABOUT

PATIENTS WITH
POSSIBLE HEAD
INJURIES OR OTHER
DISEASE PROCESSES
KNOWN TO IMPAIR
COGNITION.
as hypoglycemia, seizure/postictal phase,
dementia, CVA, etc.). Be very careful about
leaving patients behind who have central
nervous system impairment and who you
believe would otherwise benefit from ambulance transport. EMS providers need to be
able to perform a thorough mental status
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exam (beyond alert and oriented) and be

aware of different signs of intoxication.
3. Does the patient have a factual understanding of their medical condition? It
need only be a laypersons level of understanding, as evidenced by statements like,
Youre worried a blood vessel in my heart
is blocked, or This pain in my stomach
might mean I have internal bleeding after
my car accident, or Since Im taking a
blood thinner, there might be bleeding in
my brain after I fell. Can the patient understand the risks and benefits of ambulance
transport? Can they describe the risks of
not being transported? Have the patient
articulate them. Common risks are a condition that worsens and theres no provider
to intervene or that without intervention
they are likely to die. There are no risks to
ambulance transport. (Getting into a crash
is not a risk; medical risks are things like
bleeding during an operation, not that the
hospital might catch fire.)
4. Can the patient reason and come to

a decision with a certain degree of logic?
Perhaps the patient can talk about a medical condition and its possible consequences,
but is still making an illogical decisione.g.,
I know youre worried Im going to bleed
to death, but bad things dont happen to
me, so I dont need to go. This is an illogical conclusion. Finally, does the patients
decision present as rational and stable
across time? This may be the hardest for a
field provider to assess, but when it comes
to whether the decision is rational, I ask,
What makes you decide this way? When
the rationale for the decision is oddlike
Im not going to the doctor because the
mind control beams tell me not to!question whether its a rational decision.
In a hospital setting, the more serious the
decision being made, the more scrutiny is
placed on the process that leads to that
decision. For example, a patient making a
decision that might lead to their death has
to demonstrate an extraordinary capacity for making such decisions. In the field,

there may not be time to perform a thorough decision-making capacity evaluation
that rises to this level. Further, many EMS
providers may not feel comfortable documenting that they let a person die instead
of transporting because they documented
the patient had sufficient capacity to make
such a decision.
EMS systems do not typically have ethics committees or attorneys on speed dial
because in an emergency, there is considerable leeway given to simply doing what
seems to be in the patients best interest. If
the EMS provider believes the patient has
impaired decision-making capacity and a
bad outcome will happen if that patient
is not transported, most EMS systems will
permit an intervention over the patients
objections. That is, the patients autonomy
takes second place to intervening in a lifeor limb-threatening emergency.
EMS1505

23
GUEST EDITORIAL
A patient with impaired decision-making

capacity and a serious medical condition
needs a capable person to start making
decisions on their behalf. That may be
is no ill intent. In the case of the person

stabbed in the abdomen, it is unlikely he
has enough decision-making capacity to
let him decline care.
I BELIEVE PATIENTS
HAVE THE RIGHT TO
MAKE INFORMED
DECISIONS I DONT
NECESSARILY AGREE
WITH.
Conclusion
the EMS provider or a family member in

conjunction with the EMT or paramedic.
This should never be seen as kidnapping. While some patients are transported over their objections, this is a
medical intervention to go the hospital.
Ransom demands arent made, and there
In summary, I believe patients have a right

to make informed decisions I dont necessarily agree with. As EMS providers,
we have to be careful about thoroughly
assessing decision-making capacity and
mental status, following protocols for
patients who refuse transport, and documenting every encounter. Many systems
also mandate discussing such cases with
online medical control. Savvy EMTs and
paramedics develop methods for resolving patients concerns about being transported. Sometimes its as easy as making
sure a pet will be cared for or a loved one
is contacted.
REFERENCES
1. Brock DW. The idea of shared decision making between
physicians and patients. Kennedy Inst Ethics J, 1991; 1(1):
2847.
2. Lo, B. Assessing decision-making capacity. J of Law Med &
Ethics, 1990; 18(3): 193201.
3. Jones RC, Holden T. A guide to assessing decision-making
capacity. Cleve Clin J Med, 2004; 71(12): 9715.
ABOUT THE AUTHOR

Thom Dunn, NRP, PhD,
is an assistant professor
of psychological sciences
at the University of
Northern Colorado.
Additionally he is a
clinical psychologist at
Denver Health Medical
Center. Thom has been involved in EMS
for nearly 30 years and is a part-time
paramedic field instructor for the Denver
Health Medical Center Paramedic Division.
Reach him at thomas.dunn@unco.edu.
Visit us online and start your own leadership plan!

www.ColumbiaSouthern.edu/EMSworld | 877.258.7153
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24
STUDENT INTERVIEWS
Its your best early chance

to spot candidates not
suited for EMS
By Mike Rubin
This article
is the first in
a three-part
series about
interviewing
techniques.
In Part 1,
EMS World
columnist
Mike Rubin
discusses
student
interviews.
ave you ever worked

with someone you felt
didnt belong in EMS?
I think most of us have.
We tell friends, family
members and even each other that
EMS isnt for everyone, yet we meet
colleagues who seem to have missed
that message. Perhaps its anxiety or
immaturity or a poor grasp of medicine that makes it hard for them to
fit in. Whatever the cause, an EMS
provider who fails to thrive in our
profession risks compromising not
only themselves, but also patients
and partners.
EMS educators often are in the best
positions to spot misdirected prospects before they make poor career
decisions. An early and often effective way for instructors to intervene
is through student interviews.
An interview is a decision-support tool that allows two parties to
evaluate an area of mutual interest.
It works best when the interviewer
and interviewee come prepared to
exchange information and are equally proficient at verbal and nonverbal
communication. This article focuses
on practical techniques for the interviewerusually a faculty member.
Something to Talk About

Evaluating candidates abilities to
master the science of EMS is essential, but anyone whos worked in
EMS knows being book smart
isnt enough. Equally important is
whether applicants can apply didactic material to practical scenarios.
That was my biggest challenge as a
paramedic student.
Given classroom variables like
multiple instructors and diverse
student backgrounds, not to mention
the unscripted nature of real EMS,
interviewers should try to judge sub-
jects maturity and adaptability. To

what extent will candidates capabilities grow to accommodate increasing demands of the program? Are
applicants flexible enough to tolerate
unimagined stressors?
Its also wise to consider whether
candidates might become laborintensive students. Not only are
high-maintenance learners disproportionate drains on classroom
time, but disruptive or inconsiderate
pupils can compromise the reputations of their schools during practical rotations.
25
STUDENT INTERVIEWS
Measuring Performance: An Inexact Science

Earlier I used the word estimating to characterize interviewing because
the practice is inherently imprecise. Theres no evidence any of this
works, says Werfel.
Even the best interviewers reach mostly subjective conclusions about
applicants. Often the most realistic way to measure subjects performance is to compare them to each other.
Some institutions ask interviewers to grade candidates independently
on numerical scales, but force-fitting such scores to applicants responses
often leads to goal-directed manipulation of point totals. It works something like this:
Candidate A was pretty good, so I score her a 7 out of 10.
Candidate B was even better. I give him an 8.
Candidate C is good toobetter than A but not as good as Bso Im
making C a 7 and dropping A to 6.
My subjective comparison of the three candidates determined their
scores. Instead of assigning contrived point values during interviews, I
could have maintained a relative ranking or yes, no and maybe lists of
candidates, including a sentence or two about my impressions of each.
Another practice of questionable value is requiring applicants to submit references.
I havent found them helpful at all, says Werfel. The only ones that
are credible are the bad ones, and youre not likely to see too many
of those. Instead we ask students where they took their EMT course
because then I can call their instructor. Thats much better than any personal references.
Homework for Faculty
ABOUT THE
AUTHOR
Mike Rubin is a
paramedic in Nashville,
TN, and a member of the
EMS World editorial advisory board. Contact him
at mgr22@prodigy.net.
26
Estimating probabilities, through interviewing, that

subjects will conform to academic and behavioral
criteria is a skill requiring focus and tact. Preparation is essential.
Begin by considering your in-house resources: Will
you be conducting interviews alone, or can you invite
colleagues to participate? Group interviews have a
few advantages:
Members of an interview team can listen to a
subjects answers without necessarily having to think
of the next question.
Interviewers can play different rolee.g., a timekeeper, a fact-finder to make sure all biographical
details have been collected, a philosopher to engage
subjects in free-form dialogue.
Interviewers personal biases play less of a role
in decisions reached by consensus.
Tasking candidates with multiple concurrent
stimuli simulates what theyll face in the field. Nervousness is normal; paralyzing anxiety is an impediment best recognized in advance.
According to Paul Werfel, director of Stony Brook
Universitys paramedic program since 1993, team
interviews work best when everyone in the group
has a vested interest in the outcome.

You want people who are legitimately interested in
interviewing studentsnot someone who has nothing else to do, says Werfel. I dont usually ask PA or
nursing faculty to help interview because they dont
have skin in the game like my instructors do.
Shannon Lankford, EMS training officer at Tennessees Williamson Medical Center, prefers to interview
prospective students one on one.
I think a panel interview is like a firing squad,
Lankford says. Ive been through several of those as
an interviewee; theyre always more intimidating.
Lankford adds that an interviewers body language
can help put subjects at ease.
I try not to cross my arms; that looks defensive, she
says. Id rather make it easy and relaxingmore like a
conversation. Its best when theres no desk between us.
The best interviewers arent just talkers, says Werfel; like athletes, they read situations and react: You
need to be able to ask questions and listen to the
answers. You shouldnt be cutting the subjects off.
Ask open-ended questions and let people talk. Their
answers will father other questions youll want to ask.
Werfel says its important to consider high-yield
questions before the interview.
A good interviewer has to walk in with some kind
of agendaquestions they need to find answers to. If
youre interviewing students, whats their scholastic
history? Whats their motivation for choosing your
program? Have they actually done any research?
We have people whom we ask, Why do you want
to be a paramedic? and they say, I dont know, I never
gave it much thought. Not what you want to hear.
Ask them if theyve considered how the course will
impact their lives outside of school. Sometimes that
answer tells you more than anything else about their
expected longevity in the program.
Lankford favors career-oriented questions too.
I want to know about future goals, she says.
Questions such as What do you like about the
thought of doing this? and What are your concerns
and fears about getting into this field? make it harder
for a student to give us the usual Im just here to help
people answer.
Case-oriented questions can be another good
source of feedback.
We usually ask an integrity-based question, Werfel says. For example, Suppose your partner gives the
wrong drug and tells you not to say anything. What
would you do? That might give you some insight
into a problem with integrity or judgment. Theres no
way of fixing those problems in a course like ours.
If time and schedules permit, gather the members
of your team for a few simulated interviews. The practice subject

should be an experienced interviewer who can play a range of
personalities, from an introverted, ill-prepared student to the
most boisterous candidate.
Judgment Day
Interviewers should encourage candidates to ask questions too.
Applicants who see their interviews as conversations rather
than interrogations often learn more about the opportunities
theyre pursuing and presumably make better decisions about
continuing or halting the application process. Thought-provoking questions from subjects can also indicate sincere interest
and good sense.
How candidates dress is another indication of their judgment,
Werfel notes. Most of our applicants look like theyre showing
up at a baseball gamejeans, shorts, tank tops, he says. That
goes to maturity.
Be careful, though; I once interviewed a guy who arrived
in an oil-stained work shirt. I asked him if that was his normal
dress. He said, No, I left work to do this. I really need to get
into this course. I make allowances for that.
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A GOOD INTERVIEWER HAS TO

WALK IN WITH SOME KIND OF
AGENDA, QUESTIONS THEY NEED
TO FIND ANSWERS TO.
By broadcasting an inclusive attitude, rather than an exclusive
one, interviewers encourage students to speak freely. Candidates
who are at ease sometimes make accept-or-reject decisions easy.
I was interviewing a young man who seemed to be talking
to the bulletin board in my office instead of me, says Lankford.
When I asked him about it, he said, Yeah, I guess I talk to things.
Sometimes I hear music when they answer me. Needless to say,
he didnt get very far.
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Summary
Student interviews help ensure a match between classroom imperatives and candidates capabilities. Exploring students maturity and
judgment is often more important than confirming their academic
proficiency.
Walking into an interview unprepared can be as damaging
for interviewers as for interviewees. Selecting the right people
and the right process for conducting interviews depends on
planning and practice. A team approach to interviewing can be
particularly effective if team members take the time to discuss
topics and roles before meeting with candidates.
Although imprecise, interviews increase the chances that
instructors and students will achieve mutually satisfying results,
particularly when students play active roles.
Next time well cover patient interviews.
For more EDUCATION/TRAINING response

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www.mooremedical.com/emstraining
Phone: Mon.-Fri. 8am-8pm [ET]
800.234.1464
www.mooremedical.com/ems
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registered trademarks are the property of their respective owners. 2015 Moore Medical LLC. #7144
CONTINUING EDUCATION
Best Practices in CE
How technology is changing the way we deliver continuing education

By the CECBEMS Board of Directors
he Continuing Education Coordinating Board for Emergency

Medical Services (CECBEMS)
was founded in 1992 under the
vision and guidance of Janet
Head, then president of the National Association of Emergency Medical Technicians
(NAEMT).
Janet recognized that not all EMS continuing education (CE) was of a level or
quality she would expect for practicing EMS
providers. Thus she sought support from the
leadership of other EMS leadership organizations such as the National Association of
EMS Educators (NAEMSE), National Registry of EMTs (NREMT), American College of
Emergency Physicians (ACEP) and National
Association of EMS Physicians (NAEMSP).
Together these organizations provided
representation to the CECBEMS Board of
Directors. Their collective goal became to

raise the bar of EMS CE by setting standards and requirements and providing an
accreditation service for EMS-based CE.
Among continuing education providers, a broad spectrum of CE delivery and
educational methodology exists. Some CE
providers (CEP)i.e., services that offer
CE activities to EMS providers (EMSP)
offer CE in the form of live lectures EMSP
can sign up for and attend. Others provide
distributed learning (DL) in the form of
written-word-only documents tied to short
post-tests. Some providers administer CE
through online written-word activities,
PowerPoint activities, short videos and
video-based case studies.
While CECBEMS goal is to standardize
EMS CE, consumers are free to pick and
choose which format they would like to use
Photo in tablet Jones and Bartlett Publishers. Courtesy of MIEMSS.
28
for CE hours. Unfortunately, the culture of

faster and easier permeates EMS CE to a
degree, and the EMS industry as a whole
will need to reject this philosophy as we
look forward to creating a more professional
profession.
Evolving Educational
Technologies
In recent months, the CECBEMS Board
of Directors has witnessed a technological
evolution of DL activities available to EMSP.
Some truly innovative DL designs have led
to a shift in consumer/marketplace loyalty
toward the innovation and away from the
more traditional education formats.
INNOVATION IS
DRIVING EVOLUTION
IN CONTINUING
EDUCATION.
Clearly, this new generation of EMS
providers has greater access to technology
that provides instant information at their
fingertips, and they are not as interested in
traditional education. Instead, they yearn
for innovation, for flash and activities they
can accomplish on the go without being
tethered to a teacher or a classroom.1
Accredited providers and CECBEMS
accreditation applicants must commit significant resources to the production and
delivery of the activities listed in their catalogs. High-quality CE activities are not inexpensive to produce regardless of the type
of presentation. As [continuing education
expert Chuck] Karayan stated, the quality
of the presentation must meet or exceed
the investment the student makes to view
and participate in the activity.2 It is in this
light that the CECBEMS Board of Directors
would like to highlight best-practice models
in EMS CE accreditation, particularly where

innovation is driving evolution in continuing education.
New CE Models
Virtual instructor lead training (VILT)
VILT is a new distributed learning technology that allows an instructor to present information by means of a lecture when
students are only present in a virtual classroom. Students log in to the classroom and
are able to view and hear the presentation.
They interact with the instructor either by
voice and webcam video or by typing questions in a fashion similar to a chat room. All
pieces of the activity occur simultaneously.
Students are typically assigned textbook
chapter reading before the event. At the
end of the session, the students are given
a unique code that grants them access to
a post-test.
Video-based training with supporting

documents
This is a DL format in which the students
watch video narration and case presentations. They are given supplemental reading
and creative handouts to complete. After
each step in the process, they are allowed
to take a post-test for CE credit.
Integrated testing
Integrated testing ensures students complete the content requirements by writing
the post-test into the content. In other
words, a student progresses through an
interactive video training program. At key
points in the video the student is given a
question or short series of questions that
must be completed before the student may
progress to the next section. Failure to correctly respond to the questions returns the
student to the relevant section in the video
so the content can be reviewed. The question is then presented again. This is a great
way to ensure student participation.
Virtual graphics training with integrated

testing
In this case, the DL provider offers a smartphone/tablet application that allows the
student to interact with the presentation
and practice skills. The student uses his/
Accreditation Delivery
CECBEMS, by its charter, maintains
the standards for the delivery of EMS
CE. Those standards include requirements for active medical direction, valid
post-tests, quality infrastructure, sound
educational design including delivery
methodology, marketing, fees, evaluation, student record-keeping and data
reporting.
CECBEMS accreditation exists so that
EMS providers have access to highquality standard-driven continuing education activities and are awarded credit
for participating in such activities. One
of the greatest challenges of delivery
of CECBEMS accreditation is ensuring
that CE providers accurately report the
names, certification numbers, certification state, activity numbers and CEH
hours earned by subscribers (EMS providers). It is of the utmost importance
that CE providers accurately report
data to the CECBEMS data management center so each and every EMS
provider gets credit for the CE they
complete. CECBEMS depends on the
quality of the data it receives. EMTs and
paramedics depend on CECBEMS to
provide accredited programs that are
less likely to be subject to audit by the
National Registry of EMTs or individual
state EMS offices.
Much work is being done to make
the assignment of CEH objective and
her fingers to interact in a case scenario

that may require them to move equipment,
prepare equipment, prepare a patient for a
procedure, perform a procedure and evaluate a patient before and after each procedure is completed. This format also provides
integrated testing such that each question
reinforces the procedure or skill the student
is practicing.
This educational format is very expensive
and difficult to prepare, but the interactive
nature of the presentation is portable and
dynamic for the student. The area of virtual
graphics training has great potential in the
near future as technology advances and educators are able to integrate more sensitivity
and complexity into the software.
accurate but the subjectivity variable

will always be present to some degree.
CECBEMS expects that all continuing
education content is:
Relevant for the intended audience;
Medically accurate;
Properly referenced;
Original work that is correctly cited;
Grammatically correct with accurate
spelling;
Not misleading.
CECBEMS also requires the following:
Providers will cite and reference
recent peer-reviewed journals as much
as possible;
Content areas cannot be skipped and
post-tests cannot be completed until
the content has been viewed;
CE hours will be correctly applied.
For example, a provider will not award 2
CEH for a 20-minute activity;
Student activities and interactions
will be recorded, tracked, analyzed and
reported to the CECBEMS data management system;
Students will be required to evaluate
the program on completion of the lesson;
The program committee will analyze
the evaluations to make decisions on how
they need to improve their activities;
Needs assessments are performed
and their results are applied to future
educational content.
Best Practices of CECBEMSAccredited Applications

The involvement of a qualified medical
doctor (MD) is integral to the success of
any EMS education program. CECBEMS
requires that an MD sit on the program
committee and expects that the MD will
review each and every activity before the
CECBEMS application is complete and
before it is made available to the EMS community. The MD must ensure accuracy and
relevance of each activity delivered.
Aggregate needs assessments can be carried out that review the nature and breadth
of an EMS service or EMS service area to
determine the educational needs of a large
group of EMS providers. Needs assessments
29
The High-Tech Future of Continuing Education

Q&A with CECBEMS Executive Director Jay Scott
With more than 30 years as a paramedic
and an extensive background in EMS
education, Jay Scott brings an abundance of experience to his new position
as executive director of the Continuing
Education Coordinating Board for EMS.
He also brings familiarity, having chaired
CECBEMS board of directors.
Scott, BS, NREMT-P, took office in
November. Its a good fit at a dynamic
time for continuing education, with
advancing technology rapidly changing the face of how personnel get their
hours. On the occasion of the release
of the CECBEMS Best Practices Model
Document for CE providers (published
here), EMS World spoke to Scott about
the evolution of EMS continuing education and his goals for the organization.
How did your extensive background in
EMS and education help prepare you
for your role as executive director of
CECBEMS?
Well, Ive always been passionate about
the provision of EMS care, and even more
passionate about making sure EMS providers get what they need. That includes getting credit for the time they spend being
trained. Its one thing to spend evenings,
weekends and holidays away from your
family for work, but its something else
to ask people to spend time away from
their family members and friends to go do
continuing education. So its imperative for
me that people get credit for the time they
spend in training. And that training should
exceptionally well donewell prepared,
credible, relevant and exactly what EMS
providers need.
Juan March and Jay Scott are featured

speakers at EMS World Expo, Sept.
1519 in Las Vegas.
30
What is the role of CECBEMS in helping

to achieve that and advance the EMS
profession?
When we formed back in 1992 under the
guidance of Janet Head, who was then
the president of NAEMT, her overriding
goal was that we standardize continuing
education so that every CE opportunity is
a high-quality opportunity. We didnt want
any more of, Lets meet at the firehouse
Friday night and talk about things that
have been out of protocol for 10 years.
We know EMS is a very dynamic profession
and things change every day, and we have
to stay on top of that.
If the continuing education programs
arent up to snuffif they dont stay
ahead of the constant changes and this
current evolution were going through
then were not going to prepare a very
good EMS provider. If we want to have
the best EMS system anywhere, we have
to make sure the educational piece stays
in pace.
With the rapid changes in areas like
technology, how should CE providers
approach that? What should they be
doing to prepare and move into the
future?
One of the reasons the board of directors prepared the best practices model
document was that weve seen a dramatic
change in the technical ability of continuing education providers. Those changes
have been absolutely amazing. Weve seen
a shift away from the traditional approaches, like reading a magazine article and
getting credit for it or reading an online
presentation thats written-word-only, then
can be produced by survey of what EMS providers feel they need; review of EMS call data;
review of quality improvement data; review of
patient outcomes; and review of population
demographics. Needs assessments can also
be carried out on an individual level. In these
cases, the criteria listed above are reviewed
taking a short post-test. People are gravitating more toward the higher-end stuff:
the narrative videos, the cell phone applications. Those are the things people want
to seeit has to be interactive and flashy,
but also relevant and current.
Those are the trends now, and its fascinating to watch. Back when I started,
our first monitor was the Lifepak 5, and
there werent a whole lot of functions. It
defibrillated, it read an EKG, and we could
hook it up to a monitor and transmit an
EKG, and that was pretty much it. But as
technological changes happen, continuing education programs have to keep up
with the times.
When CE providers prepare to seek
accreditation for their programs, are
there areas they commonly overlook or
that frequently delay the process? What
trips people up?
I think the things people tend to underestimate when they prepare their applications
are 1) the participation of a system-wide or
service-level medical director whos active,
involved and has EMS experience, and 2)
that theres an active program committee.
We actually like to see some description of
how the medical director interacts with the
program committee and how the workings
of that committee help set their educational agenda.
The needs assessment is built into
that as well. Folks may not to do a good,
careful, detailed needs assessment, and
instead just say, Well, lets just do the
same stuff next year we did last year.
Thats not what EMS providers want. They
want new; they want to see things that
and applied to an individual EMS provider

and a custom-tailored CE program is identified, defined and initiated.
This article is taken from CECBEMS Best
Practices in Continuing Education document
available for download at http://cecbems.org.
are pertinent to their everyday practice,

things that are coming six months from
now. What are the big changes? What do
I have to prepare for?
So doing a valid needs assessment,
having an active program committee and
medical director, and, for us, seeing the
documentation of how those pieces interact and develop an educational agenda,
and how thats presented to the EMS providers, and then the way they get a chance
to evaluate thatthose are the things that
are most often missing. The description
of how all those pieces fit together should
provide for EMS providers a valid, relevant
continuing education agenda.
What goes into a good needs
assessment? What sort of things should
a provider look at?
There are many ways to do it; I dont think
theres any one gold standard. However,
personally I think a needs assessment really ought to be based on call volume and
quality improvement initiatives. If an EMS
provider has done really well with their
management of STEMI and STEMIs a large
part of their call volume, do we really need
to focus on STEMI? Maybe we should focus
more on the things that provider sees less
of. For instance, I havent done a live delivery in probably eight years, so maybe in
my continuing education program it would
be appropriate to spend some time practicing and studying up on live deliveries, in
case I have to face that in the field.
A real needs assessment looks at the
system as a whole, based on call volume
and call trends, but also what the individual is doing. How has the individual
responded to their particular calls, and
how should their service match up the
educational agenda for that individual?
The time has passed where we just say,
REFERENCES
1. Aran Levasseur. Teaching Innovation Is About More
Than iPads in the Classroom. Media Shift, www.pbs.org/
mediashift/2012/07/teaching-innovation-is-about-morethan-ipads-in-the-classroom198/.
2. Chuck Karayan. The Problem with Continuing
Education. American Surveyor, www.
amerisurv.com/PDF/TheAmericanSurveyor_
KarayanTheProblemWithContinuingEducation_
May2005.pdf.
This month were going to cover traction

splinting. Thats not good enough. We
should be covering what the individual
needs to see, based on what they havent
done recently.
What was the purpose of putting
together the best practices document?
As weve seen this dramatic shift in the
technological abilities of continuing education providers, we thought in order to
really improve the applications for accreditation, and ultimately the provision of continuing education, we should detail some
of the best practices weve seen. These
are areas where some CE providers really
stand out above the rest.
You outline some of these new
technologies in the paper; whats new
and exciting?
Some of them are really amazing. Theres
one provider who has a three-dimensional
platform using a smartphone where you
can practice skills on your phone at any
time. You can be sitting in your ambulance
at 3 in the afternoon and practice pleural
needle decompression. And its really not
that expensive.
You also mention new training for
reviewers to go along with that. What
will that entail?
Where we have reviewers who havent necessarily seen all these recent technological
changes, well need to get them up to
speed. Weve also seen a couple of unfortunate instances where some continuing
education providers have used educational
products from other CE providers. That
doesnt happen often, but there have been
three cases in the last 12 months.
For our reviewers to be able to recognize works that arent original, that maybe
need to be flagged, thats a big push for

us. Weve written a document to help
them recognize things that arent original
early in the application process. Were
training them to look through the whole
reference list, to be sure they go back and
do a Google scholar search to make sure
the references match up with the content,
the objectives match the content and references, and so on.
Its really kind of putting all the puzzle
pieces together. So when we look at a
particular offering, were looking at the
objectives, were looking at the needs
assessment that led to that set of objectives, were looking at how the program
committee put that list of objectives
together based on the needs assessment
and the input of the medical director, and
were looking at the content to see that
its all relevant and matches the needs
assessment and the objectives. And then
were looking at how its referencedthat
people are using peer-reviewed journals
and current textbooks and textbook
chapters from well-known authors written
within the last couple of years.
Thats a lot different from looking at an
offering on, say, management of chest
trauma and seeing the author cited a sole
textbook that was the Brady paramedic
manual from 1990. EMS has evolved a lot
since 1990!
You and the chair of CECBEMS
board, Dr. Juan March, are speaking
at EMS World Expo. What will you be
addressing?
Ill be doing a lecture about CECBEMS,
the accreditation process, how it came
about, what we look for and how it all
improves the educational activity. Dr.
March will talk specifically about the best
practices document.
The CECBEMS Board of Directors includes Juan A. March, MD, FACEP,

chair; Robert A. Loftus, BS, NREMT-B, vice chair; Sean Trask, MPA,
EMT-P, secretary-treasurer; Richard Beebe, MS, RN, NREMT-P; Stephanie
Davis, DO, FACEP; Andy Gienapp, MS, NREMT-P; Joe Holley, MD, FACEP;
Gabriel Romero, MBA, NREMT-P; Robert Wales, BS, CCEMT-P, NREMT-P;
Elizabeth Sibley, former executive director; and Jay M. Scott, BS, NREMT-P,
executive director. Contact CECBEMS at 972/247-4442; jscott@cecbems.
org; http://cecbems.org.
31
EMS RESEARCH
Why Research Is
Important in EMS
Michael Gerber is a
featured speaker at
EMS World Expo, Sept.
1519 in Las Vegas.
We need an evidence base, and you can help develop it
By Mario J. Weber, JD, MPA, NRP, & Michael Gerber, MPH, NRP
operate blindly when addressing issues such

as system design, resource deployment and
clinical interventions.
Since then, many EMS leaders have
been advocating for evidence-based clinical interventions in the prehospital setting.
In 2008, the National Highway Transportation Safety Administration convened
a meeting of EMS stakeholders to discuss
the development of national evidence-based
guidelines (EBGs) for EMS. Six years later,
the first national evidence-based guidelines
were released, including guidelines for prehospital pain management,2 pediatric seizures3 and external hemorrhage control.4
The overarching goal of the national EBG

development process has been to transition
to the use of high-quality evidencerather
than consensus or expert opinionas the
basis for clinical guidelines in EMS.5 Ongoing EMS research is critical to developing
the evidence base necessary to support the
use of both new and existing clinical interventions in the prehospital setting.
First Do No Harm
One of the guiding maxims for all healthcare providers is to first do no harm. The
sad truth, however, is that several clinical
interventions employed as standard prac-
Photo courtesy Richmond Ambulance Authority, RAAEMS.org
ine years ago, in its comprehensive report on EMS in the

United States, the Institute of
Medicine (IOM) said, The
prehospital emergency care
system provides a stark example of how
standards of care and clinical protocols
can take root despite an almost total lack
of evidence to support their use.1
The report found that half of EMS interventions lacked an adequate evidence base
(or had no evidentiary support at all), compared to only 5% that were supported by highquality evidence. The IOM concluded that as
a result, EMS systems in this country often
32
tice in EMS have been found harmful to

patients. Military anti-shock trousers
(MAST) are a prime example. Adopted by
EMS in the 1970s under the premise that
they temporarily reversed hypotension in
trauma patients, they were removed from
most ambulances after research in the late
1990s showed they did not improve patient
outcomes and may even have increased
mortality.6
More recently, research on endotracheal
intubation in the prehospital setting has
generated intense debate in EMS regarding the potential harm from performing advanced airway management in the
field.7,8 Even oxygen administrationlong
the mainstay of prehospital care for a variety of medical conditionshas fallen under
suspicion due to the potential harm from
free radicals and hyperoxia.9 A recent study
found high-dose oxygen may harm some
patients presenting with ST-elevation MI.10
This study echoes previous research that
questioned the benefit of oxygen administration for patients suffering from myocardial infarction.11
Even if not harmful themselves, clinical
interventions that lack proven efficacy in
EMS may still lead to suboptimal care for
patients by distracting from or delaying the
application of other therapies that actually
confer benefit. The evolution of prehospital
CHF treatment over the past decade provides
a good example of how evidence-based interventions have come to supplant traditional,
but unproven, therapies. Lasix, which has
never been proven effective in the prehospital
setting, has gradually fallen out of favor.12
In its place, the prehospital application of
continuous positive airway pressure (CPAP)
and aggressive nitroglycerin administration
have been proven to reduce mortality and
intubation rates.13,14 EMS research has thus
already played an important role in ensuring
better outcomes for patients suffering from
acute CHF exacerbation.
Prehospital Research Challenges

Research in the prehospital setting faces
several challenges. Researchers have relatively little control over patient recruitment,
as EMS patients call 9-1-1 at a time and place
of their choosing. As a result it is more dif-
Areas for Research

Airway managementThe safety and efficacy of advanced airway management by EMS remains under question, while the administration of high-flow oxygen is becoming increasingly suspect for certain conditions. Additional research
in the prehospital setting will be necessary to inform any changes to existing
indications for these interventions.
Cardiac arrestIn the context of out-of-hospital cardiac arrest, important
EMS research questions abound. Recently the effectiveness of mechanical CPR
devices has been the subject of much debate. Several research studies have
found the devices improve end-organ perfusion and increase return of spontaneous circulation.29 Large clinical trials, however, have concluded the devices do not
provide a benefit in terms of survival to discharge and neurologic outcome.3032
Similarly, researchers are still searching for evidence of increased survival from
the administration of cardiac medications during cardiac arrest.33,34 The same is
true for the use of impedance threshold devices, though researchers have recently presented evidence that ITDs may improve survival to discharge if high-quality
CPR is performed.35,36 More study will likely be required to confirm their findings.
TXAResearch in the prehospital setting is also needed to support the newest clinical interventions in EMS, such as the administration of tranexamic acid
(TXA) to control major traumatic hemorrhage. While TXA has been demonstrated
to improve survival in the military setting, the evidence for its use in civilian
trauma is very limited.37 No published research has examined the use of TXA in a
civilian EMS system.
ficult, if not impossible, for EMS researchers to craft an ideal study sample. Frequent
EMS users in particular tend to overrepresent certain segments of the population.16
EMS research also presents ethical barriers not always present in other contexts.
For example, obtaining informed consent
from patients in the prehospital setting
may not be possible. Consequentlyand
despite the lack of evidence for much of
the EMS standard of caredeviating from
accepted interventions under an exception
from informed consent can present a difficult ethical quandary.17 In the past year,
media attention surrounding a clinical trial
to examine the efficacy of epinephrine in
cardiac arrest has questioned whether withholding the medication (obviously without
a patients permission) would cause harm.18
A recent study, however, found that patients
themselves may be highly accepting of
exceptions from informed consent.19 The
same cannot be said for prehospital providers, as only 30% in one survey agreed with
enrolling patients in a study without their
informed consent.20
These ethical issues make it more difficult

for EMS researchers to perform well-constructed clinical studies in the field. They
also often add to the expense and length of
research trials. As an example, agencies in
Denver, Pittsburgh and Richmond (VA) are
currently participating in a study funded by
the Department of Defense to examine the
prehospital use of blood plasma in trauma
patients. To conduct the study under an
exception from informed consent, it was
necessary for the researchers and EMS agencies to spend several months reaching out
to community members through the media
and conducting public information sessions.
These outreach efforts were required in
order to give members of the community
an opportunity to opt out of the study.
Adequately controlling for extraneous variables is also problematic in EMS
research. EMS patients often present with a
variety of concomitant health issues, each of
which may contribute differently to, or even
supersede in terms of clinical importance,
the patients primary complaint. Even if a
patients underlying health problem can be
33
EMS RESEARCH
Therapeutic Hypothermia and the Limits of Hospital

Research
The implementation of therapeutic hypothermia for patients who have suffered cardiac arrest provides a recent and potentially cautionary example of the limitations of
using hospital-based research as the basis for EMS interventions. Studies conducted
in the hospital setting have shown that post-resuscitation therapeutic hypothermia
is associated with improved survival and neurologic outcome.22,23 Studies conducted
in the prehospital setting, however, have failed to demonstrate any added benefit
from commencing patient cooling prior to arrival at the hospital. In other words,
delaying the initiation of hypothermia until a patient arrives at the hospital may not
have an impact on clinical outcome.24 More worrisome is the potential for harm from
prehospital cooling (often achieved through rapid administration of chilled IV fluids),
which has been associated with an increased incidence of pulmonary edema and
greater administration of diuretics during the first 12 hours of hospitalization.25
isolated, the severity of each patients condition may also vary greatly. This is particularly problematic when studying the relative
efficacy of interventions that are generally
reserved for more critical patients, e.g., endotracheal intubation.
Similarly, the diversity of EMS systems is

also an issue for EMS research. To obtain a
representative sample, it may be necessary
to employ multiple study sites in different jurisdictions, each of which is likely to
be served by different EMS systems, each
with its own particular system design and

deployment model. Even within the same
EMS system, patients may receive different
levels of first response and transport care
(first responder, BLS or ALS). Response
times are also likely to vary, especially
between urban and rural communities.
Finally, the prehospital setting is anything but a controlled environment. Onscene interventions can take place anywhere
from a tiny hall bathroom to the middle of
a busy highway. Several factors, including
patient presentation and scene safety issues,
can influence whether patient care is provided on the scene or for how long. Interventions in the back of a moving ambulance
are necessarily constrained in terms of both
space and available resources, especially
compared to the hospital setting.
Conducting a retrospective trialusing
existing data collected from previous incidentscan sidestep some of these research
challenges while still providing a wealth of
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useful information. Similarly, sophisticated

statistical analyses can be used to minimize
extraneous influences and compensate for
imperfect study samples. That said, prospective clinical trials and proper controls are still
considered the gold standard in medical
research. For this reason, retrospective trials
are often an initial step prior to undertaking a randomized, prospective clinical trial.
These challenges have two important
implications for research in EMS. First,
because the prehospital setting differs
in many important respects from other
research settings, researchers must account
for multiple different and possibly confounding variables. Second, research conducted outside the prehospital setting (e.g.,
in the hospital) may not be easily generalizable to EMS due to the presence of these
confounding factors. For these reasons, it
is important that EMS researchers make an
effort to adapt clinical research methods
to the prehospital setting, even if it proves
more costly than simply conducting hospital-based research.21
Existing Data
Many EMS systems already collect a large
volume of information during their daily
operations. These data include information regarding incidents (type of call and
location), patients (identifying information
and medical history), clinical presentations
(symptoms and vital signs) and interven-
tions provided by EMS. In most jurisdictions these data are reported to national and
state databases such as the National EMS
Information System (NEMSIS).
For the most part, however, EMS systems have not yet been able to translate this
wealth of information into actionable clinical research.26 Part of the reason is that the
data they collect is often unreliable or incomplete. EMS providers are inconsistent when it
comes to information-gathering. Even when
The Reimbursement Link

The proven efficacy, or lack thereof, of clinical interventions in EMS may ultimately
have profound implications for EMS reimbursement. Since 2012 Medicare, the largest
payer for EMS services, has adjusted reimbursements to hospitals on the basis of a
value-based purchasing (VBP) program that takes into account factors such as patient
experience, outcomes and efficiency. A similar program will be applied to physician
reimbursement starting in 2015. It is probably only a matter of time until value-based
purchasing is extended to EMS.15 Research will ultimately prove crucial to demonstrating the value EMS provides to both patients and the healthcare system.
EMS1504S

35
EMS RESEARCH
relevant information is obtained, it may be

incorrectly entered into a patient care report.
In any case, not all jurisdictions collect or
report the same data elements. Consequently, data collection by itself is not enough to
support EMS research; EMS systems must
also strive to ensure good data quality.27
The biggest problem with the data currently collected by EMS systems is that
it frequently lacks information regarding
patient outcomes.28 As a result, data analysis in EMS is often focused on prehospital
endpoints (such as return of spontaneous
circulation following cardiac arrest) rather
than clinical outcomes (such as survival to
discharge and neurologic outcome). In order
to support quality EMS research, EMS systems must work with hospitals to implement
data-sharing that links EMS interventions
to relevant patient outcomes. For example,
electronic health information exchanges
that link EMS and hospital records may
allow EMS researchers to more easily obtain
and analyze outcomes data.
How EMS Providers Can

Contribute to Research
Steve Berry
Conducting a research project in EMS can

seem intimidating, but it doesnt have to
be. Many published studies first start as
small, internal quality improvement efforts,
often to help internally validate the results
of outside research. 38 While these internal
efforts may not yield publishable results,
they can still promote improvements within
a system. Additionally, they can be shared

locally with other agencies or at regional
and national conferences. Finally, they can
serve as the first step toward a more robust
research project that can be published in a
peer-reviewed journal.
The elimination of Lasix from the medical protocols of our own EMS agency is one
example of how a small-scale study can
inform EMS practice. In 2013 many EMS
systems across the country were already in
the process of eliminating Lasix from their
medication formularies. In addition to its
questionable efficacy in the prehospital setting, there was also concern regarding the
ability of EMS providers to accurately discern the underlying cause of a patients pulmonary edema, or even distinguish between
CHF and other respiratory presentations
(such as asthma, COPD or pneumonia). 39
Instead of immediately changing our protocols or ignoring the outside research, we
decided to conduct an internal study to see if
the results of the published studies held true
in our agency. This would not only help us
to determine how to interpret the research,
but also allow us to translate the research in
a way that EMS practitioners in our agency
could relate to and acceptovercoming the
inertia that often compels EMS providers to
continue past practices despite mounting
evidence against them.
First we reviewed every patient care
report from the previous year that documented the administration of Lasix. Next
we tasked our medical
director (who works in the
emergency department of
our primary receiving hospital) to match each of those
PCRs with a hospital patient
record for the same episode
of care. Finally we looked
at whether each patients
hospital record included
a diagnosis of CHF. What
we found was that about
half the patients to whom
our providers administered
Lasix over the year were not
ultimately diagnosed with
CHF. On the basis of that
finding, and the potential
36
harm from administering Lasix to patients

not in fluid overload, we decided to remove
Lasix from our ambulances.
For this small study, we did not perform
any formal statistical analysis or submit
to an institutional review board process.
Moreover, our results were neither publishable nor generalizable to other EMS
systems. Nevertheless, the results allowed
our agency to make an informed decision
regarding a change to our treatment protocol for CHF patients. In addition, the ability
to present concrete data to our providers
helped convince many who had initially
resisted the proposed change.
Conducting a research study for the purpose of publishing results can be a bit more
challenging, but there are plenty of opportunities. One barrier is often financial: Most
EMS agencies do not prioritize (or even contemplate) research when setting budgets or
hiring staff. While large research grants are
often limited to major research institutions
and universities, funding opportunities for
smaller studies exist. In 2013, for example,
the Alliance for Emergency Medical Education and Research (AEMER) in Virginia
awarded approximately $20,000 in research
grants to fund two different EMS-related
research projects in the state.
One of the projects funded by AEMER is
a study by our agency on the feasibility and
safety of a protocol that would permit EMS
to transport patients who do not require
emergency care to alternative destinations
such as medical clinics and urgent care centers. The AEMER grant has allowed our
agency to defray the costs of developing
an alternative destination protocol, training our providers and analyzing the results.
The results of our study are forthcoming,
and we plan to present our findings at this
years Virginia EMS Symposium.
Taking on a true research project was
a novel endeavor for our EMS agency, but
we made it more feasible by turning to
local partners for assistance. The CEO of
our local receiving hospital wrote a letter
of support during the grant application
phase. We also enlisted the help of local
emergency and primary care physicians to
evaluate the results. In addition, part of our
grant funding consists of a small stipend for
ARE YOU PREPARED?

BACHELOR
a graduate student to assist with statistical
analysis, often the most intimidating and
challenging part of a research study.
There are plenty of resources for EMS
researchers who require assistance with statistical analysis. Local health departments
often employ epidemiologists or other public health workers who have experience with
statistics. Colleges and universities, especially those with medical schools and public
health programs, usually also have students
looking for research projects to work on.
More generally, healthcare researchers are
often willing to help less experienced colleagues at each stage of the research process.
Even if a major research institution is not
accessible, doctors in the local emergency
department often have research experience,
or at least an interest in pursuing research.
Partnering with other EMS agencies on
research projects is also an option.
Conclusion
If EMS is to continue its professional evolution and become a respected member of
the healthcare community, it is critical that
prehospital clinical decisions be made on
the basis of good research. The next step
will require that more EMS providers
become actively engaged in conducting
EMS researchin order to supplement the
small cadre of academic EMS researchers
and also bolster the credibility of EMS as a
stand-alone profession that can contribute
to its own clinical development.
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REFERENCES
1. Institute of Medicine. Committee on the Future of
Emergency Care in the United States Health System.
Emergency Medical Services: At the Crossroads. Washington,
DC: National Academies Press, 2006.
2. Gausche-Hill M, et al. An evidence-based guideline for
prehospital analgesia in trauma. Preh Emerg Care, 2014;
18(s1): 2534.
3. Shah MI, et al. An evidence-based guideline for pediatric
prehospital seizure management using GRADE methodology.
Preh Emerg Care, 2014; 18(s1): 1524.
4. Bulger EM, et al. An evidence-based prehospital guideline
for external hemorrhage control: American College of
Surgeons Committee on Trauma. Preh Emerg Care, 2014;
18(2): 16373.
5. Lang ES, et al. A national model for developing,
implementing, and evaluating evidence-based guidelines for
prehospital care. Acad Emerg Med, 2012; 19(2): 2019.
6. Bledsoe BE. EMS Myth #1: Medical Anti-Shock Trousers
(MAST) autotransfuse a signifcant amount of blood and save
lives. EMS World, www.emsworld.com/10325078.
7. Wang HE, Yealy DM. Out-of-hospital endotracheal
intubationits time to stop pretending that problems dont
exist. Acad Emerg Med, 2005; 12(12): 1,245.
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EMS RESEARCH
8. Fouche PF, et al. Airways in out-of-hospital cardiac arrest:

Systematic review and meta-analysis. Preh Emerg Care, 2014;
18(2): 24456.
9. Gandy WE, Grayson S. More Oxygen Cant HurtCan It?
EMS World, www.emsworld.com/10915304.
10. Stub D. AVOID Study: Air Versus Oxygen in ST-Elevation
MyocarDial Infarction. Paper presented at AHA Scientifc
Sessions, www.cardiosource.org/Science-And-Quality/
Clinical-Trials/A/AVOID.aspx.
11. Wijesinghe M, et al. Routine use of oxygen in the
treatment of myocardial infarction: systematic review. Heart,
2009; 95(3): 198202.
12. Grayson S, Gandy WE. CHF Treatment: Is Furosemide on
the Way Out? EMS World, www.emsworld.com/10712890.
13. Williams TA, et al. Prehospital continuous positive airway
pressure for acute respiratory failure: a systematic review and
meta-analysis. Preh Emerg Care, 2013; 17(2): 26173.
14. Mattu A, Lawner B. Prehospital management of congestive
heart failure. Heart Fail Clin, 2009; 5(1): 1924.
15. Zavadsky M. Get Ready for Value-Based Purchasing. EMS
World, www.emsworld.com/11446135.
16. Knowlton A, et al. Patient demographic and health factors
associated with frequent use of emergency medical services in
a midsized city. Acad Emerg Med, 2013; 20(11): 1,10111.
17. Burns J. Seeking consent from those who cannot answer: New
light on emergency research conducted under the exception from
informed consent. Crit Care Med, 2015; 43(3): 7101.
18. Smith R, Hill G. Heart Patients to Be Given Placebo by
Paramedics in Controversial Trial. The Telegraph, Aug. 12,
2014, www.telegraph.co.uk/health/healthnews/11028692/
Heart-patients-to-be-given-placebo-by-paramedics-incontroversial-trial.html.
19. Dickert NW, et al. Patients perspectives of enrollment

in research without consent: The patients experiences in
emergency research-progesterone for the treatment of traumatic
brain injury study. Crit Care Med, 2015; 43(3): 60312.
20. Jasti J, et al. EMS provider attitudes and perceptions
towards prehospital EFIC research. Abstract. Preh Emerg Care,
2015; 19(1): 1423.
21. Hatez S. The Benefcial Failure of the FAST-MAG Trial. EMS
22. Hypothermia After Cardiac Arrest Study Group. Mild
therapeutic hypothermia to improve the neurologic outcome
after cardiac arrest. New Eng J Med, 2012; 346(8): 54956.
23. Bernard SA, et al. Treatment of comatose survivors of outof-hospital cardiac arrest with induced hypothermia. New Eng
J Med, 2002; 346(8): 55763.
24. Bernard SA, et al. Induction of therapeutic hypothermia by
paramedics after resuscitation from out-of-hospital ventricular
fbrillation cardiac arrest: A randomized controlled trial. Circ,
2010; 122(7): 73742.
25. Kim F, et al. Effect of prehospital induction of mild
hypothermia on survival and neurological status among
adults with cardiac arrest: a randomized clinical trial. JAMA,
2014; 311(1): 4552.
26. Goodwin J. Delivering on the Data: More Than 10 Years
In, Where Does NEMSIS Stand? Best Practices in Emergency
Services, http://info.zolldata.com/Portals/152170/docs/
delivering%20on%20the%20data%20%20best%20
practices%20in%20emergency%20services.pdf.
27. Garza A. What Is Data Good For? EMS World, www.
emsworld.com/10977730.
28. Mears G, Gunderson M. A seamless exchange. J Emerg
Med Serv, 2014 Jan; Suppl: 2731.
29. Westfall M, et al. Mechanical versus manual chest

compressions in out-of-hospital cardiac arrest: a metaanalysis. Crit Care Med, 2013, 41(7): 1,7829.
30. Perkins GD, et al. Mechanical versus manual chest
compression for out-of-hospital cardiac arrest (PARAMEDIC):
a pragmatic, cluster randomised controlled trial. Lancet, 2015
Mar 14; 385(9,972): 94755.
31. Wik L, et al. Manual vs. integrated automatic loaddistributing band CPR with equal survival after out of hospital
cardiac arrest. The randomized CIRC trial. Resuscitation, 2014;
85(6): 7418.
32. Rubertsson S, et al. Mechanical chest compressions and
simultaneous defbrillation vs conventional cardiopulmonary
resuscitation in out-of-hospital cardiac arrest: The LINC
randomized trial. JAMA, 2014; 311(1): 5361.
33. Lin S, et al. Adrenaline for out-of-hospital cardiac arrest
resuscitation: A systematic review and meta-analysis of
randomized controlled trials. Resuscitation, 2014; 85(6):
73240.
34. Neumar RW, et al. Part 8: Adult advanced cardiovascular
life support: 2010 American Heart Association guidelines for
cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation, 2010; 122(18 suppl 3): S729S767.
35. Aufderheide TP. A trial of an impedance threshold device
in out-of-hospital cardiac arrest. New Eng J Med, 2011; 365(9):
798806.
36. Yannopoulos D, et al. The effect of CPR quality: A potential
confounder of CPR clinical trials. Abstract presented at AHA
Resuscitation Science Symposium. Resuscitation, 2014;
130(s2): A9.
37. Cole E, et al. Tranexamic acid use in severely injured
civilian patients and the effects on outcomes: a prospective
cohort study. Ann Surg, 2015 Feb; 261(2): 3904.
38. Erich J. Conducting Research, Getting Published. EMS
39. Jaronik J, et al. Evaluation of prehospital use of
furosemide in patients with respiratory distress. Preh Emerg
Care, 2006; 10(2): 1947.
ABOUT THE AUTHORS

Mario J. Weber, JD, MPA,
NRP, is a paramedic and
field training officer
at the Alexandria (VA)
Fire Department, where
he focuses on quality
management, advanced
training and evidence-based
protocol development. He also reviews quality
assurance cases and advises on the ALS
training program for the Montgomery County
(MD) Fire and Rescue Service. Reach him at
mario.weber@m10.solutions.
Lifelong Learning and

Community Engagement
online.uwosh.edu/ferm
38
Michael Gerber, MPH, NRP,

is an instructor, author and
consultant in Washington,
DC. He is also a paramedic
with the Bethesda-Chevy
Chase Rescue Squad and
previously worked as an
EMS supervisor for the
Alexandria (VA) Fire Department. Gerber has
experience as an EMS educator and quality
management coordinator and has presented
original research at state and national
EMS conferences. Reach him at mgerber@
redflashgroup.com.
To take the CE test that accompanies this article and receive 1 hour of CE credit
accredited by CECBEMS, go to rapidce.com. Test costs $6.95. Questions?
E-mail editor@EMSWorld.com.
HELLP Syndrome
How to recognize and treat this life-threatening
complication of pregnancy
Kevin Collopy and

Sean Kivlehan are
featured speakers at
EMS World Expo, Sept.
1519, in Las Vegas.
By Scott R. Snyder, BS, NREMT-P, Sean M. Kivlehan, MD, MPH, NREMT-P, Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT
CONTINUING
EDUCATION
This CE activity is approved by
EMS World, an organization
accredited by the Continuing
Education Coordinating
Board for Emergency Medical
Services (CECBEMS), for 1 CEU.
OBJECTIVES
Define HELLP syndrome.
Discuss the pathophysiology
of HELLP syndrome.
Differentiate HELLP syndrome
from the other liver disorders
of pregnancy.
Identify the signs and
symptoms of HELLP
syndrome.
Discuss prehospital
management of the patient
with HELLP syndrome.
33-year-old female presents supine in

bed approximately 24 hours after giving
birth. She responds to painful stimuli by
opening her eyes, and she is noticeably
disoriented and lethargic when asked
questions. Her only complaint is of abdominal pain.
A primary exam reveals a patent airway, adequate
though rapid breathing, and a strong and rapid radial
pulse. Her skin is cool, pale and dry.
The patients husband and a doula are on scene.
They report the patient gave birth at home yesterday with the doulas help. This was the patients fifth
pregnancy and fifth vaginal birth. The pregnancy
was complicated by the development of gestational
hypertension in the third trimester; it was treated
with labetalol. The patient checked her blood pressure daily during the remainder of her pregnancy, and
both the doula and husband agree she experienced no
further episodes of hypertension. The patient started
having contractions yesterday around 0700 hours and
AndreyPopov /iStock/Thinkstock
had an uncomplicated childbirth at 1100. The intact

placenta delivered without complications, and some
mild hemorrhage secondary to a minor external vaginal tear stopped on its own with the application of
direct pressure. The neonate was vigorous at birth
and has been in good health since.
The husband says the patient initially complained
of an acute onset of upper right quadrant abdominal
pain that woke her at about 0600. She described the
pain as sharp, nonradiating and reproducible with
palpation. She also complained of nausea and vomited twice. At no time did she experience syncope
or complain of chest pain or pressure or discomfort, difficulty breathing, dizziness, weakness, back
pain or headache. The husband noticed she became
increasingly drowsy during the next few hours but
thought she was tired from the delivery. He used an
automated blood pressure cuff previously purchased
from a pharmacy to take the patients blood pressure,
which was 154/100 mmHg. He called the doula at
39
on all extremities. She appears puffy,

with +3 pitting edema noted to all four
Disorder
Timing
Clinical Findings
extremities.
Hyperemesis
First trimester
Nausea, vomiting, weight loss
The patients vital signs are as folgravidarum
lows: HR, 90/min. and regular; BP,
Intrahepatic cholestasis Second and third Pruritis (itching; worse at night), jaundice,
188/124 mmHg; RR, 24/min. with
of pregnancy
trimesters
fatigue, anorexia, abdominal pain, steatorrhea
adequate tidal volume; SpO2, 90% on
HELLP syndrome and
Third trimester
Abdominal pain, nausea, vomiting, malaise,
room air; and EtCO2, 28 mmHg with
preeclampsia
headache, visual changes, edema, jaundice
a normal waveform. The lead II ECG
reveals a normal sinus rhythm, and
Acute fatty liver of
Third trimester
Nausea, vomiting, abdominal pain, fatigue,
pregnancy
anorexia, jaundice
the 12-lead ECG is nondiagnostic for
any acute changes.
approximately 1000 hours. The doula also
with palpation of her upper right abdominal
What are you initial concerns with
noted the patients vaginal tear had started
quadrant. Her uterus is palpable, but theres
this patient? What does your differential
lightly bleeding again. Thats when they
no abdominal mass or rigidity present. She
diagnosis include? What is your managecalled EMS.
has not been incontinent of feces or urine,
ment plan?
The husband reports the patient has no
and you note capillary bleeding from a small
other significant medical history, takes no
external vaginal tear. The husband says the
HELLP Syndrome
medications except the labetalol and has no
tear occurred during the childbirth. The
HELLP is an acronym created to describe
allergies. Your clinical exam finds pupils
patient is drowsy but follows commands and
a syndrome characterized by hemolysis
that are 34 mm, equal and reactive to light
moves all her extremities with no apparent
(rupture or destruction of red blood cells),
bilaterally; no JVD; and mild bilateral rales
motor deficits. Distal circulation and senelevated liver enzymes and low platelet
(crackles). She winces and opens her eyes
sation are intact and appear to be normal
count.1 It is a not-uncommon life-threat-
TABLE 1: LIVER DISORDERS OF PREGNANCY, TIMING AND CLINICAL FINDINGS
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Additional complications associated with

HELLP include disseminated intravascular coagulation (DIC), abruptio placentae,
acute renal failure, pulmonary edema, liver
infarction and liver hematoma or rupture
with hemorrhage.5
Other liver disorders unique to pregnancy include hyperemesis gravidarum,
intrahepatic cholestasis of pregnancy,
preeclampsia and acute fatty liver of pregnancy (see sidebar).6 These disorders have
characteristic clinical features and timing
of onset (see Table 1) and may also progress
to severe liver dysfunction.7
Franck Boston/Hemera/Thinkstock
ening complication of pregnancy thought to

be a variant or complication of preeclampsia. Both of these conditions usually occur
during the third trimester or soon after
childbirth. HELLP is a multisystem disease that results in generalized vasospasm,
microthrombi formation and coagulation
defects. Untreated, HELLP syndrome can
lead to maternal end-organ failure as well
as fetal demise.
HELLP syndrome occurs in approximately 0.1%0.8% of all pregnancies and in
10%20% of women with severe preeclampsia or eclampsia.2 Up to 30% of women who
develop HELLP syndrome do so after childbirth, typically within 48 hours.
A previous history of preeclampsia,
eclampsia or HELLP syndrome is a risk
factor for HELLP, as is a family history of
it. One study found about 7% of women
who experienced the syndrome developed
HELLP in a subsequent pregnancy, 18%
developed preeclampsia, and 18% developed
gestational hypertension. 3 Half or more of
pregnant females affected by the syndrome
have had multiple childbirths.
The pathophysiology of HELLP syndrome
is poorly understood. What is known is that
the activation of the coagulation cascade,
secondary to influence from the placenta,
plays a major role.
When activated by thrombin, fibrinogen
polymerizes into strands of fibrin, which
form meshlike barriers in small blood
vessels such as the arterioles, capillaries
and venules. These fibrin barriers act like
strainers through which red blood cells are
forced, resulting in their destruction. This
results in the microangiopathic (small blood
vessel) hemolytic anemia characteristic of
the syndrome. Platelets adhere to the fibrin
structures, particularly in the liver, leading
to low platelet counts. Clot formation in
the hepatic vasculature leads to decreased
hepatic perfusion and subsequent ischemia
and, if uncorrected, infarction and liver failure. Liver dysfunction and failure result in
the elevated liver enzymes characteristic of
HELLP syndrome. Uncorrected, liver failure
will lead to fetal death if the patient has not
yet delivered and maternal death unless the
problem is corrected or a liver transplant
performed.
Signs and Symptoms

The signs and symptoms of HELLP typically appear in the third trimester of pregnancy, between 2836 weeks gestation. That
said, second-trimester or even postpartum
onset of HELLP is not uncommon. In one
study, 70% of all cases of HELLP occurred
peripartum (close to the end of pregnancy),
A doula is a nonmedical person who

assists a woman before, during, and
after a childbirth. These trained and
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physical, emotional, and informational
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and 30% occurred postpartum. 5

Symptoms characteristic of HELLP
include epigastric or upper right quadrant
abdominal pain (the most common symptom), malaise, nausea and vomiting.8,9 These
symptoms make it easy to mistake HELLP
syndrome for other etiologies of abdominal
pain, including cholecystitis, pancreatitis,
pyelonephritis and gastroenteritis. Any
pregnant patient beyond 20 weeks gestation or postpartum who presents to the ED
complaining of abdominal pain should be
evaluated for HELLP syndrome.10 Lesscommon symptoms include headache,
visual changes, edema with significant
weight gain, and jaundice.2
Hypertension (blood pressure more than
140/90 mmHg) and proteinuria (protein in
the urine) occur in about 85% of cases but,
unlike preeclampsia, need not be present
in patients with severe HELLP syndrome.
When HELLP is suspected based on
clinical findings, the diagnosis is confirmed
based on the presence of all the laboratory

abnormalities that make up its acronym:
hemolysis, elevated liver enzymes and low
platelet count. A typical workup in an emergency department would include an ultrasound of the right upper quadrant to rule
out cholecystitis, of the kidney to rule out
hydronephrosis, and a fetal examination. A
urinalysis would help rule out urinary tract
infection and kidney stones. The laboratory
workup would include at a minimum:11
Complete blood count with platelet
count;
Peripheral blood smear;
Chemistry profile;
Aspartate transaminase (AST), alanine aminotransferase (ALT), bilirubin,
alkaline phosphatase and lipase;
Coagulation profile and fibrinogen.
Management
Before discussing prehospital management
of the patient with HELLP syndrome, it
may be useful to understand the typical

inpatient and outpatient management a
woman with the syndrome will receive.
After a diagnosis of HELLP syndrome is
made, the initial steps in patient management include stabilizing the mother if
necessary, assessing the condition of the
fetus and deciding if immediate delivery
is required.2
HELLP syndrome with maternal hypertension is controlled with medications such
as labetalol, nifedipine and hydralazine in
both the outpatient and inpatient settings.
In patients admitted to labor and delivery
units between 2432 weeks gestation, magnesium sulfate is administered to prevent
maternal seizures, though its use as seizure
prophylaxis is controversial . In addition
to seizure prophylaxis, magnesium sulfate offers neuroprotective properties in
the developing fetus and neonate and can
decrease the incidence and severity of cerebral palsy in preterm infants.10
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In a healthy individual platelet levels

are considered normal between 150,000
Liver Disorders of Pregnancy
400,000 mm3. Platelet replacement is indiHyperemesis gravidarum (HG) is characterized by intractable nausea and vomitcated when a patient with HELLP syndrome
ing during pregnancy. Nausea and vomiting occur to some degree in 50%90% of
has platelets below 20,000 mm3 prior to a
all live births.1618 HG occurs in about 0.3%2% of all live births, with onset typically
vaginal delivery or below 50,000 mm3 prior
beginning between the fourth and 10th week of gestation and resolving by the 20th
to a cesarean section. This practice is conweek.18,19 Uncontrolled persistent vomiting can lead to electrolyte imbalance, weight
loss and nutritional deficiency that can require hospitalization.
troversial; the problem is that the adminisIntrahepatic cholestasis of pregnancy (ICP) is a rare complication of pregtered platelets will be destroyed in the same
nancy that occurs in the second and third trimesters and has a prevalence between
fashion as the patients own platelets were.
0.32%5.6% in the United States.20,21 Its exact cause is unknown, but cholestasis
Critical care transport teams should be sure
(slowing or stopping of the flow of bile from the liver and gallbladder) results in an
to determine the patients baseline and most
elevation in serum bile concentration. The most common and noticeable clinical
recent platelet counts and consider early
manifestation is pruritis, most commonly localized in the palms and soles of the
platelet administration.
feet.
The final treatment for HELLP syndrome
Preeclampsia is a disorder characterized by hypertension, edema and proteinis delivery of the fetus, and it is considered
uria that occurs after 20 weeks gestation. It affects about 5%10% of all pregnant
the only effective treatment.2 Immediate
woman and typically occurs late in the third or late second trimester and can also
delivery is indicated when the pregnancy
occur postpartum.22 It is thought to occur secondary to abnormalities in placental
development that result in widespread vasoconstriction. Severe preeclampsia is
is greater than 34 weeks gestation, there are
characterized by the onset of edema and neurologic symptoms such as headaches
signs of fetal stress, or with severe materand visual disturbances, nausea and vomiting. The onset of grand mal seizures in a
nal complications such as DIC, multiorgan
woman with preeclampsia indicates eclampsia is present.
dysfunction, liver failure or hemorrhage,
Acute fatty liver of pregnancy (AFLP) is a rare but potentially fatal complication
renal failure, pulmonary edema or abrupof pregnancy that occurs in the third trimester. Occurring in approximately one in
tio placentae.
every 7,00015,000 pregnancies, AFLP has a maternal mortality rate of 18% and a
In the prehospital setting, initial managefetal mortality rate of 23%.23,24 The disease is the result of a defect in the gene that
ment of the patient with HELLP syndrome
controls mitochondrial fatty acid beta-oxidation. When the defect is present, fetal
centers on airway, breathing and circulafatty acids accumulate in the mothers liver, leading to hepatic dysfunction.
tion. Place patients with an altered level of
consciousness in a position that facilitates
an open airway, most commonly supine or
inadequately should be ventilated with a
tilated via a BLS airway. Bag-mask ventisemi-Fowlers. When positioning a pregbag-mask device and receive endotracheal
lation of a pregnant female can be made
nant female supine, take care to prevent
intubation if they cannot be adequately venmore difficult by the need for greater airway
the gravid uterus from compressing the vena cava, preventing blood
return to the heart and creating
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pressures, as the gravid uterus prevents normal, unobstructed diaphragm movement. In

addition, obstructed diaphragm movement
also results in a decrease in tidal volume,
requiring smaller tidal volumes and a higher
respiratory rate to achieve an adequate minute volume.
Patients who present in the field with
acute, severe hypertension secondary to
HELLP syndrome may be candidates for
treatment with antihypertensives depending on factors such as clinical presentation,
the availability of antihypertensive agents
and transport times. While there is no standard, various sources suggest initiating antihypertensive medications in patients with
systolic blood pressures greater than 160 or
170 mmHg and signs of end-organ failure
such as headache, visual disturbances, AMS,
chest discomfort or AMI and pulmonary
edema.13
Regarding specific antihypertensive
agents, a 2013 Cochrane review of drugs
for treatment of high blood pressure in
pregnancy concluded that the choice of
antihypertensive should depend on the
clinicians experience and familiarity with
a particular drug, with consideration of its
adverse effects and patient preferences. It
also said nimodipine, diazoxide and ketanserin were probably best avoided.14 That
said, the average paramedic will most likely
have one antihypertensive drug available

in their formulary, and will have limited
experience and familiarity with using it
in pregnant females with hypertension.
Accordingly, medical control should be
consulted prior to the administration of any
antihypertensive medication in a pregnant
or postpartum female.
Options for specific antihypertensives in
the prehospital environment include labetalol, hydralazine and magnesium sulfate.
Hydralazine is a smooth muscle relaxant
and often considered the drug of choice for
PROVIDERS ADMINISTERING MAGNESIUM

SULFATE SHOULD BE FAMILIAR WITH THE SIGNS
AND SYMPTOMS OF HYPERMAGNESEMIA.
initial blood pressure care because it has no
effect on a patients heart rate or respiratory
rate. Typically hydralazine is administered
IV in 1020 mg doses over five minutes and
can be repeated once. Magnesium sulfate is
another good option. However, it requires
an initial 26-gram IV bolus administered
over 2030 minutes. This requires the use of
an IV pump to ensure its not delivered too
fast. A rapid magnesium infusion is likely to
cause hypotension as well as depression of
the patients respirations and mental state,
and can lead to flaccid paralysis and death.
44
The onset of seizures in the patient

with suspected HELLP syndrome should
be managed with 2 grams IV magnesium
sulfate administered over 510 minutes;
this has been shown to be more effective
than benzodiazepines for prevention of
recurrent seizures.13,15 Magnesium sulfate
should not only be used to treat active seizures but with the permission of medical
control can also be administered as seizure
prophylaxis in patients with HELLP syndrome. The suggested dosing regimens for
magnesium sulfate vary, with loading doses
ranging from 46 grams IV over 30 minutes

and maintenance doses from 13 grams per
hour. A common regimen involves a loading
dose of 6 grams IV over 2030 minutes followed by 2 grams per hour as a continuous
infusion.13 Recurrent seizures in patients
receiving magnesium sulfate prophylaxis
can be treated with an additional 2 grams
of the drug administered over 510 minutes.
Providers administering magnesium
sulfate should be familiar with the signs
and symptoms of hypermagnesemia. Mild
hypermagnesemia can manifest with
diminished deep tendon reflexes,
headache, lethargy, drowsiness,
nausea and flushing. Moderate
hypermagnesemia can present
with absent deep tendon reflexes,
somnolence, ECG changes, bradycardia and hypotension. Severe
hypermagnesemia will progress
to paralysis, respiratory failure
and apnea, heart block and cardiac arrest.
Proper kidney function is important in maintaining appropriate
plasma magnesium concentrations, so pay particular attention to
patients with renal insufficiency or
failure. Patients with mild to moderate kidney disease can be treated
with the administration of normal
saline and a loop diuretic such as
furosemide. Patients with kidney
failure will require dialysis. Patients who

are severely symptomatic with hypermagnesemia can also be treated with calcium
gluconate 10-20 mL of 10% solution IV over
3 minutes, or calcium chloride bolus in the
setting of cardiac arrest.
If magnesium sulfate is not available or
seizures dont respond to it, benzodiazepines such as diazepam, midazolam or
lorazepam can be administered, preferably IV, though the intramuscular route can
be utilized if IV access is unobtainable. A
caution, though: All benzodiazepines are
considered category D pregnancy drugs.
Suggested dosing regimens are as follows,
though always follow your protocol and/
or consult directly with medical control:
Diazepam: 510 mg IV every 510
mins. at a rate of 5 mg/min. or less and a
maximum dose of 30 mg.
Midazolam: 12 mg bolus IV at a rate
of 2 mg/min. Repeat every five minutes until
seizures stop, to a maximum of 2 mg/kg .
Lorazepam: 4 mg IV at maximum rate
of 2 mg/min.
Because of the risk of heart failure and
acute myocardial infarction, patients with
HELLP syndrome should have a 12-lead
ECG performed and their cardiac rhythm
monitored.
Conclusion
The patient is placed on the gurney in a
semi-Fowlers position and administered
oxygen via nonrebreather mask at 15 lpm.
The crew considers CPAP but rules it out
due to the patients decreased level of consciousness and mental status. A 16-gauge
IV catheter is placed and a 1,000-mL bag of
normal saline with a macro drip set attached
is administered KVO.
Upon arrival at the ED, the patient is
intubated, the 12-lead ECG repeated and
a Foley catheter placed. A chest radiograph reveals bilateral pulmonary edema.
Laboratory findings include increased
serum creatinine and aminotransferases,
thrombocytopenia, decreased platelets,
increased serum bilirubin and hemolysis.
The patient is determined to be suffering
from postpartum HELLP syndrome complicated by DIC and is administered fresh
frozen plasma, packed red blood cells and
platelets. No urine output is collected

from the Foley catheter, and the patient is
determined to be in renal failure. Dialysis
is planned after the administration of Lasix
fails to induce diuresis.
The initial presentation of HELLP syndrome can be subtle and mimic the clinical
presentation of a benign viral or bacterial
infection. HELLP syndrome develops in less
than 1% of all pregnancies but in 10%20%
of pregnancies with preeclampsia, and up
to 30% of women who develop HELLP
syndrome do so after childbirth, typically
within 48 hours. Outcomes for mothers
with HELLP syndrome who are identified
and receive prompt medical attention are
usually good, but complications such as
liver dysfunction or failure, renal failure,
pulmonary edema and abruptio placentae
can occur and contribute to maternal, and
possibly fetal, morbidity and mortality. EMS
providers should remember this potentially
fatal complication of pregnancy in patients
both pregnant and recently postpartum.
REFERENCES
1. Stone JH. HELLP syndrome: hemolysis, elevated liver
enzymes, and low platelets. JAMA, 1998; 280: 559.
2. Sibai BM. HELLP syndrome. UpToDate.com, www.uptodate.
com/contents/hellp-syndrome.
3. van Oostwaard MF, Langenveld J. Recurrence of
hypertensive disorders of pregnancy: an individual patient
data metaanalysis. Am J Obstet Gynecol, 2015; 215(5):
624e1624e17.
4. Lachmeijer AM, Arngrímsson R, et al. A genomewide scan for preeclampsia in the Netherlands. Eur J Hum
Genet, 2001; 9(10): 758.
5. Sibai BM, Ramadan MK, et al. Maternal morbidity and
mortality in 442 pregnancies with hemolysis, elevated liver
enzymes, and low platelets (HELLP syndrome). Am J Obstet
Gynecol, 1993; 169(4): 1,000.
6. Hepburn IS, Schade RR. Pregnancy-associated liver
disorders. Dig Dis Sci, 2008 Sep; 53(9): 2,33458.
7. Kondrackiene J, Kupcinskas L. Liver diseases unique to
pregnancy. Medicina (Kaunas), 2008; 44(5): 33745.
8. Lee NM, Brady CW. Liver disease in pregnancy. WJG, 2009;
15(8): 897906.
9. Sibai BM. The HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelets): much ado about nothing? Am J
Obstet Gynecol, 1990; 162: 311.
10. Simhan HN, Himes KP. Neuroprotective effects of in
utero exposure to magnesium sulfate. UpToDate.com, www.
uptodate.com/contents/neuroprotective-effects-of-in-uteroexposure-to-magnesium-sulfate.
11. Echevarria MA, Kuhn GJ. Chapter 104: Emergencies
After 20 Weeks of Pregnancy and the Postpartum Period. In:
Tintinalli JE, et al., eds. Tintinallis Emergency Medicine: A
Comprehensive Study Guide, 7th ed. New York, NY: McGrawHill, 2011.
12. Sibai BM. Diagnosis, controversies, and management of
the syndrome of hemolysis, elevated liver enzymes, and low
platelet count. Obstet Gynecol, 2004; 103: 981.
13. August P. Management of hypertension in pregnant and
postpartum women. UpToDate.com, www.uptodate.com/
contents/management-of-hypertension-in-pregnant-andpostpartum-women.
14. Duley L, Meher S, Jones L. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database Syst
Rev, 2013; 7: CD001449.
15. American College of Obstetricians and Gynecologists,
Task Force on Hypertension in Pregnancy. Hypertension in
pregnancy. Report of the American College of Obstetricians
and Gynecologists Task Force on Hypertension in Pregnancy.
Obstet Gynecol, 2013; 122(5): 1,122.
16. Lacasse A, Rey E, et al. Nausea and vomiting of pregnancy:
what about quality of life? BJOG, 2008; 115(12): 1,484.
17. Lee NM, Saha S. Nausea and vomiting of pregnancy.
Gastroenterol Clin North Am, 2011; 40(2): 309.
18. Matthews A, Haas DM, et al. Interventions for nausea and
vomiting in early pregnancy. Cochrane Database Syst Rev,
2014; 3: CD007575.
19. Bailit JL. Hyperemesis gravidarium: Epidemiologic
fndings from a large cohort. Am J Obstet Gynecol, 2005;
193(3 Pt 1): 811.
20. Laifer SA, Stiller RJ, et al. Ursodeoxycholic acid for the
treatment of intrahepatic cholestasis of pregnancy. J Matern
Fetal Med, 2001; 10(2): 131.
21. Lee RH, Goodwin TM, et al. The prevalence of intrahepatic
cholestasis of pregnancy in a primarily Latina Los Angeles
population. J Perinatol, 2006; 26(9): 527.
22. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet,
2005 Feb 26; 365(9,461): 78599.
23. Mjahed K, Charra B, et al. Acute fatty liver of pregnancy.
Arch Gynecol Obstet, 2006; 274(6): 34953.
24. Castro MA, Fassett MJ, et al. Reversible peripartum
liver failure: a new perspective on the diagnosis, treatment,
and cause of acute fatty liver of pregnancy, based on 28
consecutive cases. Am J Obstet Gynecol, 1999; 181(2):
38995.
ABOUT THE AUTHORS

Scott R. Snyder, BS,
NREMT-P, is full-time
faculty at the Public Safety
Training Center in the
Emergency Care Program at
Santa Rosa Junior College,
CA. He is also a paramedic
with AMR: Sonoma
Life Support in Santa Rosa, CA. E-mail
scottrsnyder@me.com.
Sean M. Kivlehan, MD,
MPH, NREMT-P, is an
emergency medicine
resident at the University
of California, San Francisco.
E-mail sean.kivlehan@
gmail.com.
Kevin T. Collopy, BA,
FP-C, CCEMT-P, NREMT-P,
WEMT, is clinical education
coordinator for VitaLink/
AirLink in Wilmington,
NC, and a lead instructor
for Wilderness Medical
Associates. E-mail
ktcollopy@gmail.com.
45
PERFORMANCE MEASURES
Should Response Time Be

A survey of Pinnacle thought leaders opinions
or decades many EMS systems have gauged performance

by measuring how fast they respond to emergencies. With
citizens expecting a quick response and limited data on
other aspects of performance, response time became one
of the few ways to assess the quality of an EMS system.
In recent years, however, many industry leaders have begun to
question the benefit of measuring and evaluating systems based only
on response times. Shaving seconds or even minutes off response
times seems to benefit only a small subset of clinical conditions. At
the same time, meeting response-time standards can cost communities hundreds of thousands of dollars. Yet community officials and
the public often still expect rapid responses to every calland the
media frequently points out when those expectations are not met.
46
With payers looking for ways to tie reimbursement to quality,

measuring the effectiveness and efficacy of EMS will soon be
more critical than ever. At this years Pinnacle EMS Leadership
Forum, leaders of the EMS industry will gather to discuss the
most critical issues they face today, including the importance of
performance improvement and the EMS Compass initiative to
develop a system of performance measures. The one performance
measure that gets the most attentiongood and badis response
time. We asked several Pinnacle faculty members to address these
questions: Are response times a good measure of an EMS systems
performance? Should EMS agencies continue to design systems
around response-time goals? Here (edited for length and clarity)
are their answers.
a Performance Indicator?
Brian LaCroix, President, Allina Health EMS
o. But ignore them at your peril.
If EMS is the practice of medicine, measuring
the value of a system based on how fast you drive
seems archaic and overly simplistic. However, it
wasnt all that long ago when all most ambulance
agencies had to offer was a quick response.
Prior to the 1960s, most well-intended ambulance
drivers had two skills: comfort around chaos and
driving fast. This rapid-response model was rooted
in the experience of our of police and fire colleagues.
Driving fast
is not a key
indicator of
quality.
Brian LaCroix
But the majority of EMS calls are not related to

time-sensitive problems. There are certain calls
when response time is important, but that list is a
small one, and its shrinking over time (think how the
proliferation of AEDs has shifted the importance of
getting an ALS rig on scene). I concede there is also
a huge issue of perception. In an emergency there
is often a high degree of anxiety, and the sooner
someone shows up to help, the sooner that anxiety
might be relieved.
But speed is dangerous. It is well documented that
the higher the collision speed, the more serious the
consequences in terms of injury and material damage. Most studies demonstrate that the time saved
driving with lights and siren is modest at best. So
if we decide to drive fast to save time, we ought to
be sure we need to perform some sort of lifesaving
intervention that is time-sensitive. Otherwise it does
not make sense.
I opened these comments about response times by
saying Ignore them at your peril. This is an acknowledgement that even though there are plenty of reasons
to slow down, responses times are still the common
currency by which the general public judges quality in
EMS. For now we cant ignore that. But its incumbent
on EMS leaders to continue to educate the public that
EMS is indeed the practice of medicine, and driving
fast is not a key indicator of quality.
Steve Knight, PhD, Senior Associate, Fitch & Associates

esponse time has historically been used as a surrogate measure for system effectiveness. The
assumption was that faster is better: The quicker
the system responded, the higher the quality of
clinical outcomes. Recent evidence-based research
has allowed us to better understand the relationship
between clinical outcomes and response times. This
current research has suggested that our response
times have little impact on clinical outcomes outside
a small subset of call types. From this perspective,
response time is not the best measure of system performance, and greater emphasis on developing evidence-based measures of clinical quality is required.
However, establishing a systems response-time
performance is still a good method of articulating
service levels to the community and stakeholders and
for holding the system accountable for performance.
I suggest this should continue until such time that
we have a robust set of evidence-based clinical measures that are readily available and easily accessible.
Through this lens, the fact that the desired service
level is established and reported, and the system is
held accountable, may have greater value than the
response-time measure itself.
Bruce Moeller, PhD, Assistant County Administrator,

Pinellas County, Fla.
You must look at this from two perspectives: Does a
better response time provide greater benefit to the
patient? And can we measure it with a degree of
accuracy and consistency? Surprisingly, the answer
is: not really.
The literature shows that response time has a
positive impact on patient outcome in only a small
number of cases. And therein lies the problem: We
expend significant energy and resources to address a
relatively small number of incidents. It is understood
that if your family member is in distress, you want
an almost-instant response from EMS. But is this the
best use of limited public resources? What should
the response-time criteria be? Historically EMS
response-time criteria were developed for cardiac
arrestsabout 1% of cases. And in cases of trauma,
many agencies struggle to get patients off the scene
quickly and to definitive care, thereby mitigating the
impact of a rapid response time.
Greater
emphasis on
developing
evidencebased
measures of
clinical quality
is required.
Steve Knight, PhD
Time is easy
to measure
response times
are not.
Bruce Moeller,
PhD
47
2015 Pinnacle
EMS Leadership
Forum
The Pinnacle EMS
Leadership Forum is
the premier event for
EMS leaders from all
service models, for
every size of service.
Sponsored by Fitch &
Associates, it is now in
its 10th year. Pinnacle
2015 will be held at the
Omni Amelia Island
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pinnacle-ems.com.
We have done
a very good
job of training
our customers
to expect us to
arrive at their
emergency
within an
average of six
minutes.
Norman Seals
Time is easy to measureresponse times are not.

We still have no universally accepted definition of
response time that utilizes the same start-the-clock
and stop-the-clock criteria. Research found EMS
agencies in Florida used nine different definitions of
response time. More important, these agencies had
a bias to use a definition that made them look better. When a single performance metric is used so
frequently and so publicly, there is motivation for
some EMS managers to worry about public perception
rather than focusing on patient outcomes.
In Pinellas County we overcame ambiguity by using
a single response-time definition, from agency dispatch until arrival on scene, for all 19 providers in our
system. And since we have all the data in a regional
computer-aided dispatch (CAD) system, ensuring a
first responder response time of less than 7:30 for
90% of incidents is relatively easy.
Response time can be a valuable performance
metric for EMS agency design. However, until we
use it thoughtfully and honestly, it will continue to
have limited utility.
Norman Seals, Assistant Chief, Dallas Fire-Rescue

As an industry we have historically touted the importance of response times, and our various oversight bodies have been trained to expect that measure in our
regular reports. We have also done a very good job of
training our customers to expect us to arrive at their
emergency within an average of six minutes. However,
I believe we need to begin reeducating those groups to
understand that, with the exception of cardiac arrest
and a few other critical conditions, response times do
not have significant impact on patient outcomes.
EMS leaders and administrators need to shift our
strategic planning processes away from response-time
metrics to the value-based metrics that appear to be
looming. Within my agency, we report annually on
average response times for our EMS units. We have
begun the process of educating city management
and city council on the changing face of EMS and
the projected impacts of healthcare reform on our
EMS operations. Additionally, we are working with a
consultant to develop plans for moving forward with
realigning operations to meet the coming changes.
Scott Matin, MBA, Vice President, Clinical, Education
and Business Services, MONOC
Over the last decade we have learned that this obsession weve had for years with response time as a measure of performance is grossly inaccurate. Research
has shown that with the exception of high-acuity
calls such as cardiac arrest, myocardial infarction,
48
EMS agencies
need to stop
designing
systems around
response-time
goals.
Scott Matin, MBA
stroke, airway obstruction and severe trauma, the
majority of calls to which EMS is dispatched arent as
time-sensitive and dont show better outcomes with
a more rapid response. Additionally, emphasis on
response time may have unintended consequences
such as more motor vehicle crashes and skill degradation when increasing the number of paramedics
answering a finite number of calls.
EMS agencies need to stop designing systems
around response-time goals. While EMS systems
need to meet public expectations, these expectations
should be weighed against available resources and the
ultimate good of the community. For EMS agencies
to effectively convey the message that faster doesnt
always mean better, they must open an ongoing dialogue with their communities. Agencies need to communicate what quality is in EMS and how it can be
obtained. Programs that can lead to better outcomes
include a robust first responder system utilizing current police and fire resources; public education on
how to identify strokes and heart attacks and when to
call 9-1-1; and community-wide education and buy-in
to develop a public-access CPR and AED program.
Greg Mears, MD, Medical Director, ZOLL

Systems of care evaluate the outcomes of patients
with time-dependent illnesses and injuries from first
healthcare provider contact through definitive care.
As a result, EMS is challenged to provide a timely
response to a subset of patients that is small compared to the overall number of EMS responses. EMS
should continue to build systems to quickly identify
and ensure timely lifesaving care for cardiac arrest,
trauma, STEMI, stroke and acute airway compromise. Other EMS responses can be managed using
time intervals that are acceptable to the EMS systems
community and customer expectations.
EMS should
continue to build
systems to ensure
timely lifesaving
care.
Greg Mears, MD
For at least
some calls,
fast response
times really
do matter
clinically.
Todd Stout
Measuring an
EMS systems
performance
requires far
more than
a single
performance
measure.
Skip Kirkwood,
MS, JD
Todd Stout, Founder and President, FirstWatch

Response times are one of many potentially important
measures of an EMS systems performance. While the
current discussions seem to focus on the fact that
they are clinically significant in only a very small
percentage of our calls, I believe that for the foreseeable future, response times will remain emotionally
significant for the patient, their family, bystanders,
etc. So if we believe the patient experience is important, or if reimbursement is based partially on patient
satisfaction at some point, response times will remain
relevant.
Another factor that cant be dismissed is that
there is a decent percentage of calls where a delayed
response time may not affect the patient or family,
but would leave another responding public safety
agency on scene waiting for an ambulance to arrive.
Third, for at least some calls, fast response times
really do matter clinically, so for those calls, monitoring response-time compliance is still important
and should remain so. I believe its just as wrong to
say response times dont matter as it is to say all
response times matter; perhaps we just need to examine the evidence to determine which calls they matter
for and what those times should beand even stratify
response-time requirements based on call types.
Finally, response times were an accepted measure
of quality in EMS for many years. And the variables
and inputs that need to be adjusted to improve
response times are actually fairly straightforward.
So while the importance of response times may be
changing, if a system has struggled to have good
response times, its likely to struggle just as much
with meeting other, more difficult-to-address quality measures.
For the reasons above, I believe response-time goals
(perhaps with better stratification) should still be
part of good system design. EMS systems are complex in any situation, so I should be clear that no
single aspect of a system should be the entire focus
of system design.
Skip Kirkwood, MS, JD, Director, Durham County (NC) EMS
It is fashionable to say, The evidence shows response
performance doesnt matter. That is not a complete
or correct statement of the science. There is little
to show that the ambulance response interval, by
itself, improves clinical outcomes. However, thats
the beginning of the discussion, not the end. Most
of these studies focus on whether the patients on one
side of the line do better than those on the other. Since
response performance is part of the total time from
event to definitive care, prompt response is important
to a patient suffering from stroke, STEMI, trauma or

other time-sensitive infirmity. Some time-sensitive
interventions (like defibrillation in cardiac arrest) do
not require an ambulance, so we need to look at EMS
systems, not just ambulance response performance.
There is much work yet to be done on this topic.
Measuring an EMS systems performance requires
far more than a single performance measure. If you
ask customers, prompt response matters. How
prompt? Who knows? Its probably never been studied
from that perspective. But other things matter also.
The quality of clinical medicine matters, although
patients and their families are probably ill-equipped
to judge that. Good, meaningful internal quality
improvement programs are essential to defining a
good EMS system. Competent employees matter,
and competence should improve with experience, so
employee turnover, satisfaction and engagement are
important measures. And good stewardship of the
publics money also matters, so a variety of financial
performance measures are also important.
We need to first agree on a set of benchmark performance measures we can use fairly and equitably
across all the business models in EMS. Then we need
to use those to educate our communities as to precisely what makes a good EMS system. Only when
we can do that will we be able to push the speed
demon out of first place as the measure of an EMS
systems performance.
The clock is
always going to
be a factor in
the EMS field.
Chris Cebollero, MS
Chris Cebollero, MS, Senior Partner, Cebollero &

Associates
In EMS we seem to live and die by the clock, but there
has been no real proof that a response-time standard
truly makes a difference. Ever since the late 1970s,
when a report written by Dr. Mickey Eisenberg stated
that quick initiation of CPR and prehospital medical treatment were serious elements in the survival
of sudden cardiac arrest patients, it has been falsely
quoted as setting a response standard of 8:59.
In todays EMS field, first responder agencies arrive
on scene within five minutes for most calls. Patients
with life-threatening conditions now have certified
responders able to place rescue airways and use AEDs
long before a transport unit arrives.
49
As we move into the future, more concentration

needs to be placed on patient outcomes, patient satisfaction and transporting patients where they need
to go for the best care. With that said, the clock is
always going to be a factor in the EMS field. What
finally needs to be done is factually coming up with
what that response-time standard needs to be.
In todays
instant
society, a
long wait at
any point in
the service
cycle will be
perceived
negatively.
Jay Fitch, PhD
Jay Fitch, PhD, Founding Partner and President, Fitch

& Associates
Years ago EMS systems were designed with a oneresponse-time-fits-all approach to 9-1-1 calls. More
contemporary research has demonstrated that
extraordinarily short response times are only clinically required in a small number of call types.
Most would agree that solid self-help instructions at
dispatch and a quick response by uniformed personnel
(fire, law enforcement or volunteer first responders)
provide a stabilizing influence for the incident. These
may be more important to clinical outcomes on some
types of calls than an 8:59 response by the ambulance.
Response times have to be engineered, measured and
managed to balance the risk to the patient, the caregiver and the community. Not every 9-1-1 request
merits a hot response from the system.
That said, customer satisfaction is part of one of the
three elements of the Triple Aim. Patients and families want their EMS system, including the transport
component, to flow smoothly and quickly. In todays
instant society, a long wait at any point in the service
cycle will be perceived negatively. Some communities
have been willing to pay the additional costs of having short response times but now feel compelled to
reassess the implications of those decisions in light
of other financial priorities. Stakeholders must be
educated that sending the correct type of help, which
is able to manage the patients needs within a reasonable time frame, may be more important than
considering response times as the primary measure
of performance.
Pinnacle 2015 will be held at the Omni Amelia

Island Plantation Resort, near Jacksonville, FL, August
3-7, 2015. For more see pinnacle-ems.com.
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FIRE-BASED MIH-CP
MIH Summit 2015 Report

Lessons learned from a fre-based MIH-CP Program
By Michael Gerber, MPH, NRP
n Tuesday, April 28, more than 200

EMS leaders gathered in Arlington,
VA, for EMS Worlds Mobile Integrated Healthcare Summit, held in
conjunction with the National Association of Emergency Medical Technicians EMS On
The Hill Day.
The audience heard from several leaders and innovators discussing topics such as the need for reimbursement reform in EMS, how to fund MIH-CP
programs and how to measure program performance.
The highlight of the program came when agency
representatives from a diverse group of EMS providers
described how they established MIH-CP programs
and what lessons they
learned along the way.
One of those programs
included the Dallas
Fire-Rescue Department
Mobile Communit y
Healthcare Program.
Dallas recently completed the first year of its
program, which aims to
reduce 9-1-1 calls for EMS services among

the most frequent users. According to Dallas
Fire-Rescue Assistant Chief Norman Seals,
a panelist at the MIH Summit, the program
exceeded expectations during its first year.
Weve seen an 83.5% reduction in their 9-1-1
utilization over a years time, Seals said of the 73
patients enrolled in the program. Were monitoring
them one year post-graduation or removal from the
program, and its sticking. Its working.
Seals shared some lessons learned during the development and implementation of Dallass program,
several of which were reiterated by other speakers
throughout the day.
Mobile
Integrated
Healthcare:
Part 6
eginning in January, EMS World

launched a yearlong series that provides readers with a road map for
developing MIH-CP programs. This series
will address the following topics:
Planning for rapid implementation;
Data metrics and outcome measures;
Updates on CMS Innovation Grants;
Collaborations with home healthcare;
Accreditation of MIH-CP programs;
Payer perspectives for MIH-CP services;
Choosing practitioner candidates;
Education of MIH-CP practitioners;
MIH-CP programs in rural settings;
International models of MIH-CP.
This month we report from the 2015 MIH
Summit held April 28 in Washington, DC.
Empower the Team

One of the keys to Dallas success, Seals says, has
been the autonomy given to the group of paramedics chosen to plan, implement and staff the Mobile
Community Healthcare Program (MCHP).
One of the most critical parts in doing one of
these programs is you choose the right people, you
train and educate them to the best extent possible,
and then you empower them to make it their own
program, says Seals.
In Dallas, department leaders chose five paramedics out of many who applied for the program; Seals
described them as enthusiastic volunteers, some who
Norman Seals (pictured

far left) participated on
several panels at the
MIH Summit.
51
FIRE-BASED MIH-CP
nearly cried tears of joy when they were selected to

be a part of the new initiative.
They are invested wholeheartedly in this project
and they love what theyre doing, says Seals.
Not only did Dallas carefully select who would be
a part of the MCHP team, the agency also gave those
paramedics several months to learn about healthcare
reform, MIH-CP programs, city resources and other
critical pieces of putting a program together. The
fire department then took its time putting together
a program instead of rushing to start.
Learn Case Management

Many of the presenters at the MIH Summit discussed
the importance of learning case management in order
to find the best solutions for frequent utilizers problems.
Its not necessarily what we in the fire service or
EMS as a whole do, says Seals, explaining that case
management is in some ways the antithesis of the
traditional EMS model of rapid response and rapid
transport. Mobile integrated health uses completely
different concepts than fire departments are used
to, adds Seals.
Find Community Partners

To learn the case management process in Dallas, the
MCHP team reached out to people with experience
who could teach the paramedics and help the team
manage its patients. This was just one example of
how Dallas Fire-Rescue reached out to community
partners during the development and implementation of its program.
Our network has grown exponentially, says Seals.
Its amazing to see the community respond to what
were doing.
Other speakers at the summit shared similar stories
about discovering organizations in the community
that provided services that their patients needed.
By continuously attending meetings and discussing
their MIH-CP programs, they successfully
expanded their networks and found
new partners.
What we found in Dallas is
that we have this huge number of
resources that are available to help
these people. There are hundreds
of organizations, says Seals. Yet
theres been a huge gulf between [the
organizations and the people who need
their services]. Somehow these people
fall through the cracks. Were helping to
bridge that chasm that lies between the two.
Active Medical Direction

In addition to connecting with a network of city and
community resources, the paramedics in Dallas also
benefited from the support and advice of a medical director who wasand isintensely involved in
the program. Marshal Isaacs, MD, FACEP, has been
actively advising the team, helping them create plans
for patients and helping Seals communicate with the
rest of the medical community.
I had to learn a new language. [Hospital administrators] speak a different language than firefighters,
says Seals, crediting Isaacs with teaching him how
to talk to hospital leaders, advising the audience that
the medical director should be by your side every
step of the way guiding and directing what youre
trying to do.
Involve the Legal Team Early

Although the Dallas MCHP team has received strong
support from city leaders, Seals recognized the importance of transitioning from a program subsidized by
the fire departments budget to one that is sustainable.
Very early on, [the city manager] said It sounds
like a very good idea, well fund it for a little while,
butand yall know what comes nextyoud better
make it pay for itself as quickly as possible, says Seals.
Part of that process has involved negotiating contracts with hospitalsSeals said the department is
close to inking its first deal. Half a dozen hospitals
right now are begging for a draft contract. They want
to put money in my hand, he said.
But Seals said the biggest hurdle to date has been
educating the city attorneys. He advised others to
bring their legal teams in during the early stages of
planning, both to get their counsel on issues and to
give them time to learn the aspects of healthcare law
they may not be familiar with.
Municipal attorneys are not specialists, he says,
so theyre going to have to wrap their head around
a whole new set of requirements.
Despite some of the obstacles theyve faced,
Seals was optimistic about the future of the
Dallas program, saying they hope to expand
it beyond the five paramedics currently seeing patients.
I could easily see in a few years time having 40 or 50 paramedics in our program and
a whole command structure, he says, adding
that the program presented an opportunity to
make a difference in peoples lives unlike anything hed done in the fire department before. Ive
been doing this job for nearly 30 years and this is
by far the coolest thing Ive ever been involved in.
Next Month:
Payer
Perspectives
52
New this year: MIH-CP

track at EMS World
Expo, September 1519
in Las Vegas, NV.
ABOUT THE
AUTHOR
Michael Gerber, MPH,

NRP, is an instructor,
author and consultant
in Washington, DC. He
is also a paramedic with
the Bethesda-Chevy
Chase Rescue Squad
and previously worked
as an EMS supervisor
for the Alexandria
(VA) Fire Department.
Gerber has experience
as an EMS educator and
quality management
coordinator and has
presented original
research at state
and national EMS
conferences. Reach
him at mgerber@
redflashgroup.com.
EMS STATE OF THE SCIENCES CONFERENCE: REPORT FROM THE GATHERING OF EAGLES
The 17th annual EMS State of the Sciences Conferencemore commonly referred to as
the Gathering of Eaglesconvened in Dallas, TX, on February 20 and 21, 2015.
This event is famous for its 10-minute bullet plenary presentations, lightning rounds
and other innovative educational advances, delivering 60+ presentations over two days,
which, according to conference evaluations, change nationwide medical practices almost
overnight. Comprised of the jurisdictional EMS medical directors from the nations largest
municipalities and their counterparts in pivotal federal agencies, the faculty is responsible
for the care of nearly 100 million citizens and is influential in shaping future EMS practice
trends worldwide.
Over the next few months, we will share highlights from the conference, which presents
cutting-edge information and advances in EMS patient care, clinical research and systems
management.
This month we write about two presentations that looked at expanding the use of ultrasound technologies into the prehospital arena for patients in cardiac arrest.
Eagles host and program coordinator Paul

Pepe addresses members of the faculty.
Using Prehospital Ultrasound for

Cardiac Resuscitation
By Ed Mund
Presentation: Ultrasound in Prehospital

Cardiac Resuscitation. Presented by Drew
Harrell, MD, Medical Director, Albuquerque
Fire Department, Associate Director, UNM
EMS Medical Direction Consortium
DREW HARRELL, MD, medical director
for the Albuquerque Fire Department and
associate director of the University of New
Mexico EMS Medical Direction Consortium, discussed utilizing part of an existing
trauma-based ultrasound procedure to help
guide care of patients in cardiac arrest. His
session, Ultrasound in Prehospital Cardiac
Resuscitation, began with acknowledging
the key role prehospital providers play in
that effort.
Harrell said EMS has a history of being
early adopters of new technologies or transferring technologies proven in emergency
departments to the prehospital setting.
In the early 1990s, he noted, there was a
groundswell of interest in new technology, but much of it didnt stickpossibly
because it was not used in the correct
areas. He believes focusing on prehospital
cardiac arrest can bring better results.
Cardiac arrest is one prehospital disease process where the entirety of initial
resuscitation occurs outside the emergency
Parasternal Long
department, Harrell said. We own that

patient from the time of the event until
return of circulation.
Harrell believes the FAST (focused
assessment with sonography for trauma)
examination is a starting point for moving ultrasound into the field. FAST is a
helpful, noninvasive means of identifying
fluid where it does not belong in trauma
patients. When examining with ultrasound

in the subxiphoid position, the operator
can observe the presence of any pericardial fluid and how much squeeze effect
the heart is producing.
Harrell said one common indicator for
use would be where a patient is showing
pulseless electrical activity (PEA): We
often have the hardest time on patients
53
EMS STATE OF THE SCIENCES CONFERENCE: REPORT FROM THE GATHERING OF EAGLES
with extended PEA. If we could look and

find additional signs to support continued
care, we could better serve the patient. We
could change methods and pharmaceuticals to be more appropriate to the patients
needs.
Another condition where being able to
image the heart movement with ultrasound
would be useful is in what Harrell called
really, really fine asystole. Ultrasound
offers huge opportunities to make better
treatment decisions, he said.
Harrell cited a 2010 study from Hennepin County, MN, where paramedics were
trained in FAST and aortic aneurysm ultrasound examination techniques in a six-hour
course. During the study, 104 patients who
were being transported for cardiac condi-
tions were examined by paramedics during transport, after all other emergency
care was provided. Follow-up reading by
physicians agreed with 100% of the medics exam interpretations. Most important,
according to Harrell, was that pericardial
fluid was found in 7% of the exams, potentially leading to altering patient care.
That study shows there certainly is an
opportunity. The results speak volumes to
the fact that its technically doable in the
field and trainable for field use, Harrell
said.
A 2014 survey of National Association
of EMS Physicians EMS medical directors
showed 22% of respondents considering
using ultrasound in the prehospital setting.
Harrell said the devices are becoming more
durable and cost-effective, which adds to

the allure. When we can get more than
one device that can be used over and over
for less money than a single heart monitor,
it really changes the calculus for EMS systems, he said, adding that one day we may
look at ultrasound the same way we once
did pulse oximetry and AEDs.
Harrell said it is important to keep looking at patient care, emerging technologies
and how we can use technology to improve
patient outcomes. Right now we dont
even know what we dont know, he said.
Can ultrasound be taught and fielded
successfully? Lets find out. We own prehospital cardiac arrest. This is what we do.
These are the patients on whom we are
most likely to make the most difference.
Transesophageal Echocardiography
By Ed Mund
Presentation: TEE-ing Off the Cardiac

Arrest Sand Trap: Shadow-Boxing for CPR
Vectors, Missed VF & Pseudo PEA. Presented by Scott T. Youngquist, MD, MSc, Medical Director, Salt Lake City Fire Department.
SCOTT YOUNGQUIST, MD, MSC, is
medical director for the Salt Lake City Fire
Department. He has been examining the
potential for prehospital use of a different
type of ultrasound technology: transesophageal echocardiography (TEE).
His Gathering of Eagles presentation
was titled TEE-ing Off the Cardiac Arrest
Sand-Trap: Shadow-Boxing for CPR Vectors,
Missed VF & Pseudo PEA. It discussed
how using TEE to directly visualize the
heart during cardiac arrest might address
some limitations of field assessment and
treatment. What impact would there be if
prehospital providers could, in effect, see
structures and movement inside the body?
Youngquist said the idea came as a result
of work Mike Mallin, MD, did developing
an emergency ultrasound program at the
University of Utah. Youngquist said he has
a strong interest in both echocardiography
and cardiac arrest treatment. We use TEE
in the emergency department, he asks.
54
TEE during CPR
Why cant we use it in the field?

TEE is a test that uses sound waves
to create high-quality moving images of
the heart and its blood vessels. A flexible tube is inserted down the patients
throat into the esophagus. A transducer
at its tip generates images that show the
size and shape of the heart, as well as how

the chambers and valves are working. TEE
can identify areas of heart muscle that are
not working properly and detect possible
clots, pericardial fluid buildup and problems with the aorta. Because the esophagus is directly behind the heart, highly
detailed images are possible.

Youngquist believes TEE has the potential to improve rhythm analysis by identifying masked ventricular fibrillation and
distinguishing PEA from pseudo-PEA. He
said it can also replace the pulse check
with a faster, more accurate visualization of
whether the heart is still or has experienced
return of spontaneous circulation.
TEE can prevent withholding appropriate care during long searches for pulses,
Youngquist said. The movement of the
heart is readily observable, leading to faster
and more accurate treatment decisions.
Youngquist said using TEE can also
improve hand placement for more effective
compressions. He referenced an ED-based
study on cardiac output using hand compressions conducted on patients with PEA
but no heart motion. Forty-four percent
of the time, hand placement was actually
occluding aortic outflow.
Given the anatomic variations in
patients, a one-size-fits-all hand placement
may not be optimal, he said. It appears
that a lower sternum placement provides

better cardiac outflow than the inter-nipple
hand placement.
It remains uncertain at this time whether
TEE can help classify the cardiac rhythm, but
Youngquist said there have been reports of
arresting patients showing asystole on the
monitor, yet VF activity with a TEE probe.
He cited the case of one who was shocked,
leading to ROSC. We dont know how
accurate modern monitors are for determining VF versus asystole, he said.
PEA shows organized rhythm on the
monitor but can be a wide range of nonsurvivable conditions. In pseudo-PEA the heart
is pumping, but ineffectively. The prognosis is different depending on if the heart is
standing still versus showing activity.
TEE may help prevent stopping resuscitation prematurely, Youngquist said. Of
course, the condition of the heart is not the
only consideration. For example, what is the
condition of the patients brain?
Using TEE to identify the cause of arrest
has ramifications on patient management.
Youngquist cited a study where TEE correctly identified the arrest cause in 65% of
patients. For 31%, this changed how they
were managed. Youngquist said TEE can
reveal signs of pulmonary embolism, cardiac tamponade, aortic rupture, aortic dissection, papillary muscle rupture and hypovolemia. Wall motion during compressions
can identify tissue damaged by myocardial
infarction.
Youngquist said field use of TEE is not
right around the corner. Key research yet to
be done includes gathering more observational data on the epidemiology of PEA.
ABOUT THE AUTHOR

Ed Mund began his fire
and EMS career in 1989.
He currently serves with
Riverside Fire Authority,
a fire-based ALS agency
in Centralia, WA. His
writing and photos have
appeared in several industry
publications. Contact him at mund.ed@
comcast.net.
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EMS Education
Knowledge and Compassion in Action
Be More.
57
LIFE SUPPORT
By Mike Rubin
Head of the Class

What makes a good EMS instructor?
Teaching is not a lost art,

but the regard for it is a lost
tradition.
Jacques Barzun, author and educator
ABOUT THE
AUTHOR
Mike Rubin is a
paramedic in
Nashville, TN,
and a member
of the EMS
World editorial
advisory board.
Contact him at
mgr22@prodigy.
net.
58
After giving and taking ACLS and PALS classes for 20

years, I generally expect less of those courses when I
attend them past the midpoint of five-year AHA cycles.
Its hard for teachers and students to get excited about
covering the same material as last time.
Thats why I was pleasantly surprised by my PALS
instructors engaging approach during a recent refresher.
Elizabeth Clinard, RNan ED nurse most daysannotated
the compulsory videos with real-world commentary and
was particularly good with first-time PALS students who
needed lots of encouragement during practical exercises.
At the end of the two-day session, the classs performance
in the dreaded megacodes was the best Ive seen.
Clinard must have understood that good teachers subordinate themselves to their material. If you think its easy
for instructors to offer expertise and decode relevance
without shifting focus from the curriculum to themselves,
try telling your significant other about something that
happened at work without making yourself the point of
the story.
On the way home from PALS, I considered how lucky I
was to have had so many outstanding lecturers during my
primary EMT and paramedic programs. Although none
of my teachers had formal training as educators, they
shared qualities that should make some career instructors envious:
CommitmentThe best teachers Ive known have
been all inas dedicated to excellence as the finest
EMS providers. So many people are affected by our performance, I cant imagine doing either job without caring about outcomes. Educators on automatic pilot miss
almost as much as their students.
CreativitySome EMS lectures can be pretty boring;
trust me, Ive given enough of them. Good instructors
try extra hard to punch up material with imagination and
even trickery. I had a teacher who used to write with
his left hand once in a while instead of his right, just to
see if anyone noticed. Sometimes hed come to class in
homemade costumes to help illustrate the days lesson.
We thought Mr. Clark was crazy, but we sure paid attention to see what stunt he would try next.
AvailabilityTeaching is one of those occupations

like medicine and law that doesnt always conform to
eight-hour days. When students or patients or clients
need you, they usually need you nownot when youre
next in your office. Unlike doctors and lawyers, though,
most teachers dont have the option of billing for their
discretionary time. Excellent educators have to be okay
with accommodating pupils sometimes-frantic, ofteninconvenient phone calls, e-mails and texts.
EnthusiasmIts difficult to get excited about presenting dry material after a busy day or night doing your
other job, but successful instructors find ways to selfstart. Whenever Id catch myself mumbling to the class
about the mysteries of that weeks body system, Id raise
my voice a notch, start walking up and down the aisles
and make eye contact with as many students as possible.
CharmI think it would be hard to thrive as a teacher without a baseline fondness for people. Successful
instructors can be serious and even strict while publicly
rooting for their students to succeed. Gaining a classs
attention without instilling fear often means adding a
measure of warmth to each days lesson plan.
KnowledgeRule No. 1 of teaching is know the materialtrite, perhaps, but Im betting most of you have
endured at least as many unprepared instructors as I
have. Trying to anticipate students questions was always
a big part of my preparation.
ExperienceYouve probably heard the saying Those
who can, do; those who cant, teach. Ive seen examples
of that, but a more accurate statement, in my opinion,
would be Many who do, cant teach. I think field experience is a necessary but insufficient prerequisite for EMS
instructors. Classroom experienceas educator and
pupilis just as important.
HumilityFormal instruction is an exercise requiring
mutual respect between teachers and students. That
sometimes breaks down when educators wait to show
respect until they get it. Ive seen much better results
when teachers begin their very first lesson with vocabulary, tone and body language that say, This isnt about
me; its about you mastering the material. Im going to
help you do that.
With self-assured wisdom, we lecture that EMS isnt for
everyone. I can almost hear a students cynical comeback:
Neither is teaching.
Authors note: Thanks, Bob, Ed, Eric, Paul and Reeve.
I was paying attention even when I looked like I wasnt.

Jun 2015

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CO V ER R EP OR T: T HE EDUC AT ION ISSUE

25 Conducting the Student Interview

32 Why Research Is Important in EMS

Richmond Ambulance Authority

46 Should Response Time Be a

By James J. Augustine, MD, FACEP

A survey of Pinnacle thought leaders opinions

51 MIH Summit 2015 Report

By Thom Dunn, NRP, PhD

Lessons learned from a fre-based MIH-CP

By Michael Gerber, MPH, NRP

By Mike Rubin, BS, NREMT-P

53 EMS State of the Sciences

EMS World Online

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