EXCLUSIVE International EMS Special Issue plus Hot Products from EMS Today

JUNE 2018

TRUCK
ATTACK
Lessons learned from
Berlin, Germany, p. 28

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1806JEMS_C1 1 5/14/18 8:06 AM

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24 VEHICLES AS WEAPONS
Lessons learned from the truck attack in Berlin, Germany
By Johannes Kohlen, EMT-P & Klaus Runggaldier, PhD, EMT-P

JUNE 2018 VOL. 43 NO. 6

32 LIFESAVING DRONES
Unmanned aerial vehicles for EMS & rescue applications
By Andreas Claesson, RN, EMT-P, PhD
Contents
36 VOLUNTEERING TO SAVE LIVES
Israel’s Magen David Adom provides nationwide EMS response
By Eli Jaffe, PhD, EMT-P; Rafael Strugo, MD & Oren Wacht, PhD, EMT-P

42 PEDAL POWER Bicycle response team rolls out on Australia’s Gold Coast
By Queensland Ambulance Service Media Unit 32

44 EPIDEMIC OF FEAR
Treating the Ebola outbreak in Western Africa
By Elvis Timothy Ogweno, MPH,MSc,EMT-P
DEPARTMENTS & COLUMNS
6 EMS IN ACTION Scene of the Month

48 HOT PRODUCTS FROM EMS TODAY 2018

8 FROM THE EDITOR Moving Forward, Looking Back
By A.J. Heightman, MPA, EMT-P
30 innovative new products showcased at the EMS Today: The JEMS 12 EMS INSIDER News and Winning Strategies for EMS Leaders
Conference & Exposition
15 PRO BONO Signing Off
By Stephen R. Wirth, Esq., EMT-P

16 CASE OF THE MONTH Broken Heart

By Brendan Mulcahy, DO, PA-C, NRP; Haley Delligatti, NRP &
36 42 Talo Capuzzi, NRP

18 SIMULATION SUCCESS People as Patients

By Timothy Whitaker, BS, CHSE, CHSOS, EMT-P; Jennifer McCarthy,
MAS, NRP, MICP, CHSE & Andrew E. Spain, MA, NCEE, EMT-P

20 STREET SCIENCE Thanks for the Feedback

By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P

21 RESILIENCY REPORT Building Resilience

By Members of the EMS Alliance on Resiliency

60 HANDS ON Product Reviews from Street Crews

By Fran Hildwine, BS, NRP

62 FIELD PHYSICIANS Lift-Assists, Refusals & Releases

By Neal J. Richmond, MD, FACEP
About the Cover
Learn how the Berlin Fire Department and other first responders coordinated medical care after a trailer 63 AD INDEX
truck was deliberately steered into a crowd of people at a popular Christmas market, pp. 24–31.
photo courtesy berliner feuerwehr 64 LAST WORD The Ups & Downs of EMS

www.jems.com jUNe 2018 | JEMS 1

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 ®

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

MANAGING EDITOR – Ryan Kelley, NREMT – rkelley@pennwell.com
SENIOR EDITOR – Sarah Ferguson, MA – sarahf@pennwell.com

MEDICAL EDITOR – Edward T. Dickinson, MD, NRP, FACEP

TECHNICAL EDITOR – Carolyn Gates, EMT-P, FP-C
MOBILE INTEGRATED HEALTH EDITOR – Matt Zavadsky, MS-HSA, EMT
CONTRIBUTING WRITER – Elisse Miller
CONTRIBUTING ILLUSTRATOR – Paul Combs, NREMT
CONTRIBUTING PHOTOGRAPHERS – Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney
McCain, Tom Page, Rick Roach, Scott Oglesbee, Steve Silverman, Matthew Strauss, Chris Swabb

EDITORIAL GRAPHIC DESIGNER – Kermit Mulkins

PRODUCTION COORDINATOR – Katie Noftsger – katien@pennwell.com
REPRINTS, EPRINTS & LICENSING – Rae Lynn Cooper – 918-831-9143 – raec@pennwell.com
DIGITAL MEDIA CAMPAIGN MANAGER – Erin Huot – erinh@pennwell.com

SUBSCRIPTION DEPARTMENT
Toll Free: 800-869-6882 / Fax 866-658-6156
International Callers: +1 512-982-4277
JEMS@kmpsgroup.com
SENIOR AUDIENCE DEVELOPMENT MANAGER – Jim Cowart – jimc@pennwell.com
MARKETING MANAGER – Ashley Cope – ashleyc@pennwell.com

SALES & MARKETING SOLUTIONS

WESTERN & CANADA – Mike Shear – 858-638-2623 – mshear@pennwell.com
MIDWEST AND SOUTHEASTERN – Melissa Roberts – 918-831-9727 – melissar@pennwell.com
NORTHEAST AND INTERNATIONAL – Rod Washington – 918-831-9481 – rodw@pennwell.com

WWW.EMSTODAY.COM
SENIOR VICE PRESIDENT/GROUP PUBLISHER – MaryBeth DeWitt
EDUCATION DIRECTOR – A.J. Heightman, MPA, EMT-P
CONFERENCE MANAGER – Debbi Wells, CMP – dwells@pennwell.com
CONFERENCE COORDINATOR – Sara Jones – sjones@pennwell.com
MARKETING MANAGER – Ashley Cope – ashleyc@pennwell.com
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FOUNDING PUBLISHER – James O. Page (1936–2004)

CHAIRMAN – Robert F. Biolchini (1939-2017)

VICE CHAIRMAN – Frank T. Lauinger
PRESIDENT AND CHIEF EXECUTIVE OFFICER – Mark C. Wilmoth
EXECUTIVE VICE PRESIDENT, CORPORATE DEVELOPMENT AND STRATEGY – Jayne A. Gilsinger
SENIOR VICE PRESIDENT, FINANCE AND CHIEF FINANCIAL OFFICER – Brian Conway
SENIOR VICE PRESIDENT/GROUP PUBLISHER – MaryBeth DeWitt – marybethd@pennwell.com

For more information, visit JEMS.com/rs and enter 2.

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 For more information, visit JEMS.com/rs and enter 3.

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UNITED STATES
Faizan H. Arshad, MD
EMS Medical Director, Vassar Brothers
Medical Center
William K. Atkinson II, PHD,
MPH, MPA, EMT-P
Health Care Advisor, Raleigh, N.C.
James J. Augustine, MD, FACEP
Chair, National Clinical Governance Board,
U.S. Acute Care Solutions
Paul Banerjee, DO
Medical Director, Polk County (Fla.)
Fire Rescue
Bryan E. Bledsoe, DO, FACEP,
FAAEM
Professor of Emergency Medicine, Director,
EMS Fellowship, Univ. of Nevada
Scotty Bolleter, BS, EMT-P
Chief, Clinical Direction, Bulverde Spring
Branch (Texas) Fire and EMS
Criss Brainard, EMT-P
Fire Chief, San Miguel Fire & Rescue
(Spring Valley, Calif.)
Chad Brocato, JD, DHSc, CFO
Assistant Chief, Pompano Beach (Fla.)
Fire Rescue
Carol A. Cunningham, MD,
FAAEM, FAEMS
State Medical Director, Ohio Dept. of Pub-
lic Safety, Division of EMS
Rommie L. Duckworth, LP
Director, New England Center for Rescue
and Emergency Medicine
EMS Coordinator, Ridgefield Fire Dept.
Mark E.A. Escott, MD, MPH, FACEP
Medical Director, Austin-Travis County EMS
Jay Fitch, PhD
President & Founding Partner, Fitch &
Associates
Ray Fowler, MD, FACEP, FAEMS
Professor and Chief, Division of EMS,
Univ. of Texas Southwestern School
of Medicine
Adam D. Fox, DPM, DO, FACS
Section Chief, Division of Trauma, Rutgers
N.J. Medical School
John M. Gallagher, MD
Medical Director, Wichita/Sedgwick
County (Kan.) EMS System
Ryan Gerecht, MD, CMTE
EMS and Emergency Medicine Physician,
Tacoma, Wash.
Jeffrey M. Goodloe, MD, NRP,
FACEP, FAEMS
Medical Director, EMS System for Metro-
politan Oklahoma City & Tulsa
Keith Griffiths
President, RedFlash Group
Andrew J. Harrell, MD
Associate Professor, Dept. of Emergency
Medicine, Univ. of New Mexico
Joe Holley, MD, FACEP, FAEMS
Medical Director, Memphis Fire Dept.
Christopher N. Kaiser, NRP
Paramedic, Central Wisconsin
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Dept.
Chetan U. Kharod, MD, MPH,
Colonel, USAF, MC, SFS
Program Director, Dept. of Defense EMS &
Disaster Medicine Fellowship
Keith Lurie, MD
Codirector, Central Minnesota Heart Cen-
ter Resuscitation Center
4 JEMS | JUNE 2018
1806JEMS_4 4
W. Ann Maggiore, JD, NRP
Clinical Instructor, Univ. of New Mexico,
School of Medicine
Shaughn Maxwell, EMT-P
Deputy Chief, South Snohomish County
(Wash.) Fire & Rescue
Andrew M. McCoy, MD, MS
Assistant Medical Director, Seattle
Fire Dept.
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator, Saratoga County, N.Y.
John McManus, Col. (Ret.), MD,
MBA, MCR, FACEP, FAAEM
Professor of Emergency Medicine &
EMS Fellowship Director, Georgia
Regents Univ.
Jason McMullan, MD, FAEMS
Associate Director, Division of EMS,
Dept. of Emergency Medicine, Univ.
of Cincinnati
Mark Meredith, MD
Associate Professor of Pediatrics, Le
Bonheur Children’s Hospital (Mem-
phis, Tenn.)
David A. Miramontes, MD,
FACEP, NREMT
Medical Director, San Antonio Fire Dept.
Brent Myers, MD, MPH, FACEP
Senior Medical Consultant, ESO Solutions
President, National Association of EMS
Physicians
Joseph P. Ornato, MD, FACP,
FACC, FACEP
Operational Medical Director, Richmond
Ambulance Authority
Paul E. Pepe, MD, MPH, MACP,
FACEP, FCCM
Professor of Emergency Medicine, Internal
Medicine, Pediatrics, Public Health,
Univ. of Texas Southwestern Med-
ical Center
David E. Persse, MD, FACEP, FAEMS
Physician Director & Public Health Author-
ity, City of Houston EMS
P. Daniel Patterson, PhD,
MPH, MS, NRP
Assistant Professor, Emergency Medicine,
Univ. of Pittsburgh
Mark Piehl, MD
Pediatric Intensivist & Pediatric Critical
Care Transport Advisor, WakeMed
Edward M. Racht, MD
Chief Medical Officer, American Medi-
cal Response
Jeffrey P. Salomone, MD, FACS
Trauma Medical Director, Banner Des-
ert Medical Center/Cardon Children’s
Medical Center
Jullette M. Saussy, MD, FACEP
Emergency Medical Physician
Geoffrey L. Shapiro
Director, EMS & Operational Medicine
Training, School of Medicine and Health
Sciences EHS Program, George Wash-
ington Univ.
Corey M. Slovis, MD, FACP,
FACEP, FAAEM
Medical Director, Metro Nashville Fire Dept.
E. Reed Smith, MD, FACEP
Co-Chairman, Committee for Tactical
Emergency Casualty Care
Walt A. Stoy, PhD, EMT-P
Professor & Director, Emergency Medicine,
Univ. of Pittsburgh
For complete bios of our Editorial Board members, visit jems.com/Editorial-Board.
EDITORIAL BOARD
Peter P. Taillac, MD
Medical Director, Bureau of EMS and Pre-
paredness, Utah Dept. of Health
Jonathan D. Washko,
MBA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ
Center for EMS
Keith Wesley, MD, FACEP, FAEMS
Medical Director, HealthEast Medical
Transportation
Katherine H. West, BSN, MSEd
Infection Control Consultant, Infection
Control/Emerging Concepts Inc.
Keith Widmeier, BA, NRP, FP-C
Director of Education, Good Fellowship
Ambulance & EMS Training Institute
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg & Wirth LLC.
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg & Wirth LLC
Wayne M. Zygowicz, MS,
EFO, EMT-P
Division Chief, Littleton (Colo.) Fire Rescue
MULTI-NATIONAL
Corina Bilger, NREMT-Ret
Director of International Sales, H&H
Medical Corp.
Ahed Al Najjar, BSc, FPHC, FAHA,
MPH, DOHS
Director of Life Support, EMS Faculty &
Researcher, Prince Sultan Bin Abdulaziz
College for EMS – King Saud Univ.
Jerry Overton, MPA
Chair, International Academies of Emer-
gency Dispatch
AUSTRALIA
Colin W. Allen, ASM
Director, Brisbane Operations Center,
Queensland Ambulance Service
Paul Middleton
Chair/Principal Investigator, DREAM (Dis-
tributed Research in Emergency and
Acute Medicine) Collaboration
Peter O’Meara
Professor, Rural & Regional Paramedicine,
La Trobe Univ. (Victoria)
Robyn Smith
Editorial Staff Member, Response
AUSTRIA
Christoph Redelsteiner,
DrPhDr, MSW, MS, EMT-P
Professor, Dept. Social Work & Health,
Univ. of Applied Sciences St. Pölten
CANADA
Randy Mellow
President, Paramedic Chiefs of Canada
Ronald D. Stewart, MD, FACEP
Professor, Emergency Medicine, Dal-
housie Univ.
CZECH REPUBLIC
Jana Šeblová, MD, PhD
Head Physician, EMS Education, Central
Bohemian Region
®
DENMARK JAPAN SAUDI ARABIA
Kjeld Brogaard, EMT-P Hiromichi Naito, MD, PhD Kenneth J. D’Alessandro,
EMS Senior Manager, Falck Denmark Assistant Professor, Dept. of Emergency BS, MS EMS, EMT-P
Freddy Lippert, MD
Medicine, Okayama Univ. Hospital EMS Program Advi er, Saudi Red Cres-
Hideharu Tanaka, MD, PhD cent Authority
CEO, EMS Copenhagen
Professor & Chairman, EMS System, William J. Leggio, EdD, NRP
Heidi Vikke, MSc Graduate School & Research Insitute of Paramedic Program Coordinator, EMS
Head of Research, Falck Denmark
Disaster & EMS, Kokushikan Univ. Education, Creighton Univ.
FINLAND KENYA SCOTLAND
Pertti H. Kiira, RN, EMT-P Elvis Ogweno, MPH, MSc, EMT-P Paul Gowens, FCPara, MSc, AASI,
Consultant of EMS Director, Tactical Search and Rescue PGCert, DipIMC, RCSEd, MCMI
Team, Africa Consultant Paramedic, Scottish Ambu-
FRANCE lance Service
Jean-Clause Deslandes, MD LUXEMBURG
Past Publisher, Urgence Practique Steve Greisch, RNA SINGAPORE
Registered Nurse Anesthetist & Continuing Marcus Ong Eng Hock
Marilyn Franchin, MD
Prehospital Emergency Physician, Fire Bri- Medical Education Instructor, Centre Senior Consultant, Clinician Scientist &
Hospitalier Emile Mayrisch Director of Research, Dept. of Emer-
gade of Paris
gency Medicine, Singapore Gen-
MEXICO eral Hospital
GERMANY
Jan-Thorsten Gräsner, Armando Alvarez, BSBME, SLOVAKIA
MBA, EMT-P, PA
MD, FERC
CEO, Sistemedic Viliam Dobias, MD, PhD
Director, Institute for Emergency Chair of Emergency Medicine, Medical
Medicine, Univ.Medical Center
School of Slovak Medical Univ. Bratislava
Schleswig-Holstein THE NETHERLANDS
Klaus Runggaldier, PhD, EMT-P Ingrid Hoekstra, MSc SLOVENIA
Dean and Professor, Medical School Ham- Ambulance Nurse, RAVU Utrecht Ambu-
Andrej Fink, MSHS , RN, EMT-P
burg, Univ. of Applied Sciences and lance Service, Dept. of Research
Head of Ambulance Service, Univ. Medical
Medical Univ.
Centre Ljubljana
Thomas Semmel, EMT-P NEW ZEALAND
ALS-Instructor, European Resuscita-
Craig Ellis, MD SOUTH AFRICA
tion Council
National Medical Advisor, St. John’s
Ambulance Service Neil Noble, CCP
HUNGARY Director, Paramedics Australasia
Hugo Goodson, MBA, PgCertEd,
Laszlo Gorove, MD BHSc
Senior Lecturer, Paramedicine, Auckland SOUTH KOREA
Managing Director, Hungarian Air Ambu-
Univ. of Technology Sang Do Shin, MD, PhD
lance Nonprofit Ltd.
Professor, Dept. of Emergency Medicine,
Seoul National University College of
ICELAND NIGERIA
Medicine and Seoul National Univer-
Njall Palsson, EMT-P Nnamdi Nwauwa, EMT, sity Hospital
President, Professional Division for CCEMTP, MBBS, MPH, MMSCEM
Founder, Emergency Response Ser-
EMT-Paramedics SWEDEN
vices Group
Styrmir Sigurdarson, EMT-P
Ola Orekunrin, MD Kenneth Kronohage, MSc,
Director of EMS, South Iceland CRNA, BSc, RN
Director, Flying Doctors Service
President, Swedish Ambulance Forum
INDIA
NORWAY
George P. Abraham, MD, FECS, UNITED ARAB EMIRATES
Carl R. Christiansen, EMT-P,
FACS, FWACS, MHA
MPhilEd
Ahmed Alhajeri
Medical Director, Western Alliance Deputy CEO, National Ambulance
Hospital Lecturer, Oslo & Akershus Univ.
EMS System
College of Applied Sciences
G.V. Ramana Rao, MD, DPH, Live Oftedahl, Cand.Philol.
UNITED KINGDOM
PGDGM
Editor-in-Chief, Ambulanseforum Jon Ellis, MBA
Director of Emergency Medicine Learn- Technical Expert, BSI & CEN Committees
ing Center & Research, GVK Emergency Ronald Rolfsen —Ambulance Systems & Patient Han-
Management Research Institute Special Adviser, Division for Prehospi- dling Equipment
tal Medicine, Ambulance Dept., Oslo
Mike Jackson, MSc (Dist), DipIMC,
Univ. Hospital
IRELAND MBA, FCPara
Steinar Olsen, RN, EMT-P Chief Consultant Paramedic & Assistant
Darren Figgis Director, Dept. of EMS, Norwegian Direc-
Advanced Paramedic, Health Service Exec- Clinical Director, North West Ambulance
torate for Health Service NHS Trust
utive National Ambulance Service
POLAND Ian Maconochie, FRCPCH, FECM,
ISRAEL FRCPI, FERC, PhD
Jamie Chebra, EMT-P, CEM,
Consultant, Paediatric Emergency Medi-
Dov Maisel, EMT-P MS, DHAc cine, St. Mary’s Hospital, Imperial Aca-
Senior Vice President of International Opera- EMS Educator & Advisor, Poland EMS demic Health Sciences Centre
tions, United Hatzalah – United Rescue Systems
Fionna Moore, MBE, BSc, FRCS,
Sody Naimer Marek Dabrowski FRCSEd, FRCEM, FIMC FCSEd
Senior Lecturer, Division of Community Lecturer, Poznan Univ. Medical Sciences, Medical Director & Consultant in Prehos-
Health, Ben-Gurion Univ. of the Negev Rescue & Disaster Medicine Dept. and pital Care, South East Coast Ambulance
Sim Center Service NHS Foundation Trust
Oren Wacht, EMT-P, PhD
Lecturer, Ben Gurion University, Dept. of Mateusz Zgoda, MPH, EMT-P Andy Newton, PhD
Emergency Medicine & Health Systems Paramedic, Krakow Rescue Public Ambu- Chief Clinical Officer, South East Coast
Management lance Service Ambulance Service NHS Trust
www.JEms.com
5/14/18 7:57 AM
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 EMS IN ACTION
SCENE OF THE MONTH

6 JEMS | JUNE 2018 www.JEms.com

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 BYSTANDER CPR

S an Diego (Calif.) Fire-Rescue lifeguards and firefighters, along with a

crew from American Medical Response, performed a CPR/AED save on a
Sunday morning in San Diego, Calif., when a 62-year-old male was fishing
and suffered a cardiac event. A bystander called for help, and the patient
received CPR and a total of five shocks from the AED before regaining a
pulse and being transported to a local hospital.

Photo courtesy Andy Lerum

www.jems.com jUNe 2018 | JEMS 7

1806JEMS_7 7 5/14/18 7:57 AM

 FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
MOVING FORWARD,
LOOKING BACK
Seeing the future’s potential as we learn from the past
By A.J. Heightman, MPA, EMT-P
I
recently had the honor of addressing the
first graduating class from the San Diego
Fire-Rescue Department’s (SDFD) para-
medic program, for which I serve on the aca-
demic advisory committee.
The ceremony was held on the top deck
of the historic USS Midway aircraft carrier,
which is now docked in San Diego bay as a
floating museum.
It was a fitting location for the historic para-
medic graduation, and it made me think about
all the reasons why the 16 graduates are now
pioneers in the next generation of EMS.
The astronauts who flew on the initial Gem-
ini missions, cramped in a single-seat capsule
with no escape hatch, later watched in amaze-
ment as advances in technology allowed three
astronauts to ride side-by-side to the moon and
back, which led to the seven who got to enjoy
A.J. addresses the first graduates of the San Diego Fire-Rescue paramedic program. Photo courtesy Monica Munoz
8 JEMS | JUNE 2018
1806JEMS_8 8
the comfort and capabilities of the massive
space shuttles. In the same way, today’s young
EMS pioneers are entering a much improved
clinical and technological world of medicine.
As I stood on the deck of the Midway, I
noticed the H-34 Seabat helicopter that was
designed in the 1950s. The Seabat helped
turn the helicopter into an effective anti-
submarine weapon.
This now antiquated, low-tech helicopter
was also used to recover Mercury astronauts
and transport them back to the safe confines of
the aircraft carrier during NASA’s early years.
More significantly, because of their age, prior
experience, maturity and entry into paramed-
icine at this point in the evolution of EMS,
the new graduates have many more options
available to them. Their depth of knowledge,
hospital clinical time and internships affords
them so much more opportunity than I had
as a paramedic student.
As a young paramedic graduate 43 years
ago, I was proud of everything I was taught,
including all of my new equipment and capa-
bilities. But, as I look back, I realize that I
was one of the “shoestring” medical pioneers.
We didn’t have the benefits of solid radio
or cellular coverage; 12-lead ECG capabil-
ity; CPAP; intranasal naloxone; impedance
threshold devices (ITDs); adult intraosseous
drills and needles; pelvic splints (vs. tied bed
sheets); mechanical CPR and extracorporeal
membrane oxygenation (ECMO) capabilities
within our systems.
For many years, I wasn’t allowed to start an
IV, defibrillate, administer drugs or terminate
resuscitations on scene prior to receiving a phy-
sician’s order. The delay in care and admin-
istration of drugs and shocks resulted in few
successful resuscitations.
These young graduates have all of this avail-
able to them—and much more.
TEACH IT BACK
During the ceremony, I recalled a fabulous
educational exercise I’d been a part of a few
months earlier—with this same group of para-
medic students.
Paramedic program clinical coordinator
Carolyn Gates and program coordinator Ted
Chialtas recently added a new session, and
had invited me to take part.
In the exercise, each student had to select
a JEMS article, read it, understand it and
develop a 10-minute presentation where they
delivered a concise analysis on the topic of
the article, including how it had an impact
on them as well as their colleagues through-
out the world.
In addition to their classmates, the audience
www.JEms.com
5/14/18 7:57 AM
 also included a panel of guests that included
SDFD’s medical director, several associate
medical advisors, senior staff and me.
Carolyn was inspired to create this exercise
after she learned about an amazing educational
experience called “teach it back” that her two
daughters, Ashley and Jackie, had when they
were in fifth grade. Their teacher would pres-
ent a lesson and then assign a student to teach
it back to the class. It required the students
to pay close attention to the content, because
they knew one of them would have to teach it
back. They were then tasked with redoing the
class in their own words and style.
Carolyn loved the exercise for its educa-
tional value, and its ability to develop each
student’s self-confidence in presenting pivotal
EMS information.
After each student presented on the signif-
icance of the article they selected, the panel
had the opportunity to either comment or ask
questions of the students.
The concept has been beneficial not only for The 16 graduates of the San Diego Fire-Rescue paramedic program, class of April 2018. Photo A.J. Heightman
learning retention, but it’s also been connected
to a reduction in medical errors.1 not only because I could hear the enthusiasm in It’s rare for students or providers to be asked
each student’s voice, but also because I realized or afforded the opportunity to look toward the
A BEACON OF LIGHT that I was hearing from the next generation future and see which capabilities can and must
The teach it back session was an amazing exer- of EMS providers who can—and will—make be advanced to save additional lives.
cise that made a powerful impression on me, an impact on what we do and how we do it. As each student delivered their presentation

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1806JEMS_9 9 5/14/18 7:57 AM

 FROM THE EDITOR
A.J. takes part in the teach it back exercise with San Diego Fire-Rescue paramedic students.
Photo courtesy Carolyn Gates
and discussed their article’s impact, I began to
appreciate how today’s providers are subject to
much more violence than I ever was.
The uptick in fentanyl abuse means provid-
ers are more susceptible to the harmful effects
of the drug if it comes in contact with their skin
or respiratory system. Chemically induced sui-
cides, where deadly gasses have been released
Skills & Experience: San Diego Fire-
Rescue April 2018 Paramedic Class
Didactic/classroom education includes
579 hours of training:
>>83 drug, protocol, ECG and pathophys-
iology quizzes;
>>10 major exams;
>>Certifications in prehospital trauma life
support (PHTLS), advanced cardiac life
support (ACLS) and pediatric advanced
life support (PALS);
>>3 written final exams; and
>>2 oral field readiness interviews.
Clinical education with live patients
includes 160 hours of training:
>>1,618 IVs established successfully;
>>1,955 doses of medications adminis-
tered; and
>>144 successful endotracheal intubations.
Field internships include 528 hours of
training:
>>2,510 9-1-1 calls run on both San Diego
Fire engines and AMR ambulances;
>>847 attempted IVs with 77.29% success;
10 JEMS | JUNE 2018
1806JEMS_10 10
from a bucket on the floor of a car, can also
kill providers if they don’t wear proper per-
sonal protective equipment (PPE) and respi-
ratory apparatus.
This remarkable learning experience also
made me realize that, in addition to these haz-
ards, there’s a beacon of light that shines over
the EMS horizon.
>>1,038 ECGs interpreted; and
>>27 cardiac arrest cases managed.
About the students:
>>The most senior graduate in the class
has served 9 years with SDFD. The least
senior graduate has served 2 ½ years;
>>April 2018 class graduated 16 of 18 stu-
dents (88.9% retention rate);
>>9 came to the program with a bachelor’s
degree—one from Harvard University;
>>2 students graduated from the U.S. Naval
Academy in Annapolis, Md.; both served
in the U.S. military (Navy and Marine
Corps), and a third is anticipating accep-
tance to an Air Force Reserves special
operations unit.
>>1 was previously an analyst for the
Department of Defense at the Pentagon;
>>4 are college athletes;
>>1 is a licensed private pilot and skydiv-
ing instructor who has completed more
than 11,000 jumps; and
>>1 holds a purple belt in Brazilian Jujitsu.
New technologies and techniques can save
providers’ backs and musculoskeletal systems,
their respiratory systems and their lives—as
well as the lives of many patients who we pre-
viously thought wouldn’t survive.
Today, in many EMS systems, mechanical
chest compression devices and ECMO keep
cardiac arrest patients alive for hours, some-
times days. These new providers are entering a
world with resuscitation capabilities that have
never before been presented: The capability to
place and maintain patients in a “suspended”
state with continuous compressions, ITDs, tar-
geted temperature management and ECMO.
These advances allow specialty centers to inter-
vene and correct problems hours and days after
a major insult to the lungs, heart and/or brain.
THE CHALLENGE OF CHANGE
Along with these new skills, technologies and
research come additional challenges that these
new pioneers will face.
The first is tradition. More experienced pro-
viders haven’t always been exposed to the same
articles and research, or had the firsthand expe-
rience of a prolonged resuscitation, a chemical
suicide or violence. Because of this, they’ll often
resist change and remain in their comfort zone.
There’s a touch of complacency that occurs
when people get used to calling a cardiac arrest
after 20 minutes, or taking patients to closer
hospitals rather than resuscitation centers that
might be blocks or miles away.
The second challenge is getting medical
centers, the recipients of these patients, to real-
ize that EMS now offers much more than it
did previously. Many of these facilities now
accept our judgment when calling trauma alerts.
However, now we’re calling in and ask-
ing them to trust our judgment with ST-
elevation myocardial infarction (STEMI)
alerts, cath lab activation, stroke alerts that
need early staff intervention, and sepsis alerts
to battle the insidious effects of infection.
Many physicians come from the “old school,”
and don’t react well to prehospital personnel
alerting them that actions are needed after we
deliver our patients into their domain.
The young pioneers of EMS are tasked
with being patient, and understanding that
these hurdles must be overcome to have new
techniques, protocols and equipment accepted
by their colleagues and hospital counterparts.
To address this, the programs that SDFD
and other educational centers have instituted
teach students to be diplomatic, well-informed
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5/14/18 7:57 AM
 PATIENT
SAFETY
and strategic. New providers are now armed with articles, research and
case studies to educate their colleagues about the tremendous capabili-
ties that we currently have—and will have—in the future.
It’s a noble mission for all new graduates, both EMTs and para-
medics, to embark on.
IS YOUR FIRST PRIORITY
LOOKING FORWARD
Early astronauts were launched into space in what they understood to IndeeLift: The safe way to lift
be a safe and technically advanced environment. They never knew what
would come after their pioneering efforts.
and transport patients
The Apollo spacecraft that successfully landed astronauts on the Indeelift protects patients and providers by eliminating
moon and safely returned them to Earth did so with, by today’s stan- manual lifting while providing greater comfort and patient
dards, a primitive computer that had just 10 megabytes of memory. dignity for both lift and transfer needs. Being dragged on
Today’s EMS pioneers have much more than 10 megabytes of stor- a tarp is not only humiliating but dangerous for the patient
age space on their phones. This gives them the ability to instantly to and provider. Give your patients the respect they deserve
look up protocols, hazmat indices, drug interactions and checklists that and do your back a favor at the same time.
allow them to deliver care faster and more effectively than in the past.
It’s an exciting and challenging time for new EMS providers who The flagship EMS model (HFL-500-E) weighs-in at only 50
choose this path because of what it has the potential to do going for- lbs. yet comfortably lifts and transports patients weighing
ward—rather than what it’s been doing for decades. in excess of 500 lbs.
It’s important that we support their efforts and respect their opin-
ions. They represent the future of EMS. JEMS

REFERENCE
1. Tamura-Lis W. Teach-back for quality education and patient safety. Urologic Nursing. 2013;33(6):
267–271, 298.



IndeeLift: Bridging the Gap Between

the Ground and the Gurney

“Indeelift is the safest way to pick up a

patient for the patient and the provider!”
— Fire Captain/Paramedic, Kurtis Dickey

Program clinical coordinator Carolyn Gates, EMT-P, FP-C, addresses the graduates
on the deck of the USS Midway. Photo A.J. Heightman www.indeelift.com
Designed and built in the USA
www.jems.com U.S. Patent No. 9,808,388 B2

For more information, visit JEMS.com/rs and enter 6.

1806JEMS_11 11 5/14/18 7:57 AM

 ™
A MISSION & A PASSION
Drew Dawson, interim executive director of NREMT,
discusses recent changes & new leadership
T
he National Registry of EMTs (NREMT) has played an integral
role in advancing the EMS profession for more than four decades.
With a staff of only 50 employees at its headquar-
ters in Columbus, Ohio, the National Registry is the only national
organization that certifies emergency medical responders, EMTs
and paramedics.
A pioneering leader in EMS, Drew Dawson was appointed as the
National Registry’s interim executive director in September 2017.
For nearly 50 years, Dawson has led the profession in a variety of
ways—from serving as Montana’s state EMS director for more than two
decades, to heading up the National Highway Traffic Safety Administra-
tion’s (NHTSA) Office of EMS from 2003 until his retirement in 2015.
Since its founding, the National Registry has been focused on main-
taining the integrity of the EMS profession. However, the perception
of its role can sometimes vary from one EMS professional to the next.
In an interview, Dawson addressed core principles of the National
Registry and clarified its commitment and importance to both individ-
ual professionals and the industry as a whole.
As a former chairman of the National Registry Board of Directors, he
stressed his role in helping prepare the organization for a smooth tran-
sition to a permanent executive director this summer.
JEMS: We know you’ve worked with the National Registry for
many years in your roles as a state EMS official and director of the
NHTSA Office of EMS. Coming to the organization as interim
A pioneering leader in EMS, Drew Dawson (left) was appointed as the National
Registry interim executive director in September 2017. Photos courtesy NREMT
12 JEMS | JUNE 2018
1806JEMS_12 12
executive director, was there anything that surprised you about the
work they’re currently doing?
Dawson: I’d worked with the National Registry in various capacities for
decades, even as chairman of their Board of Directors, but none of that
adequately prepared me to understand or to fully appreciate the amaz-
ing amount of work that goes into serving the nation’s EMS certifica-
tion organization.
The complexity of the work—ranging from test development, psy-
chometrics, test delivery networks, certification and recertification, infor-
mation systems, registrant services and personnel administration—is
challenging and, frankly, a bit overwhelming.
There are lots of moving pieces, all of which must work together
seamlessly and efficiently. I was surprised by the number of staff I didn’t
know, but soon learned they’re incredibly talented, well-educated and
universally dedicated to the National Registry’s mission of advancing
the EMS profession.
JEMS: What can you share with readers about the search for a new
executive director?
Dawson: Great question. We’re making good progress. Following in-
person interviews of the top candidates, the search committee has nar-
rowed the field and the Board of Directors will make the final selection
at their meeting on June 12. I’ll continue as the interim executive direc-
tor until the new executive director comes on board, and I will remain
on-site to assist with their transition.
We’ve made some very positive changes to the National Registry’s
organizational structure and processes over the last nine months, and
we all want the transition to be just as smooth and seamless as possible.
JEMS: The National Registry’s role isn’t always clearly understood
by everyone. Can you help us understand some of its core principles?
Dawson: First, the National Registry isn’t a “test vendor.” We’re a
full-service EMS organization whose primary focus is to provide a
reliable, predictable, patient-centered standard for state EMS leader-
ship to evaluate entry-level competence for their EMS professionals.
In the end, this translates to improved patient care.
The National Registry also provides a path to ensure the continued
competence of EMS professionals.
Secondly, sometimes people confuse National Registry certification
with a license, so it’s important to make the distinction: National Regis-
try certification verifies entry-level competency, but it isn’t a license and
it doesn’t constitute permission to practice.
Only a state government may issue a license to practice, and states
www.JEms.com
5/14/18 7:57 AM
 frequently require National Registry certification to values evidence-based decisions, we take great pride
verify competency as a basis for issuing their license. in our use of research. Basing our decisions on science
With that, the National Registry has a close partner- lends credibility to the National Registry as an unbi-
ship with state offices of EMS. ased organization that uses facts, not politics, to craft
Most importantly, you’re not a member of the policies and examinations to improve the profession.
National Registry, you’re nationally certified and can
be justifiably proud of meeting a high standard. A JEMS: What do you say to people who are frus-
national certifying body is a key element in the devel- trated with the National Registry or who say the
opment and maturation of the profession as a valuable test is too hard or irrelevant?
member of the healthcare community. For nearly 50 years, Dawson has led the Dawson: National Registry certification protects the
Additionally, the National Registry is a member profession in a variety of ways—from public by evaluating EMS competence using an exam-
of the National Commission for Certifying Agencies serving as Montana’s state EMS director ination written by a broad range of professionals,
(NCCA), the organization that accredits certifying for more than two decades, to heading up including educators, medical directors, administra-
agencies, and has to meet its comprehensive list of the NHTSA Office of EMS from 2003 until tors, state directors and current EMS professionals.
requirements for certification. his retirement in 2015. We acknowledge that the examinations are hard;
however, they’re also relevant, current and rigorously
JEMS: Why is the National Registry involved with research? evaluated. Before any question is used for assessment on an examination,
Dawson: As a nonprofit organization, we want to use our resources to help it’s been taken by hundreds of examinees as a practice item. Each item
improve EMS. We’re in a unique position to help others understand the is evaluated to ensure the content is relevant, the item is fair, and there’s
important issues of EMS, and our research helps us constantly improve only one correct response.
our service to the EMS community. Also, as an organization that highly Examination items are written by EMS educators, providers and

www.jems.com jUNe 2018 | JEMS 13

1806JEMS_13 13 5/14/18 7:57 AM

 EMS INSIDER
medical directors from across the U.S.. They’re
not written by National Registry staff. We’re
happy to answer questions and concerns about
exam content. If you’re interested in helping to
write exam items, you can sign up at our web-
site at www.volunteer.nremt.org.
JEMS: What’s the process for writing &
validating test questions and practical sce-
narios? How often are the tests updated?
Dawson: The tests are constantly being updated.
We have between 15–20 examination develop-
ment panels each year.
The panels are made up of volunteer EMS
professionals who help update the examina-
tion to reflect the values and knowledge of the
EMS community.
We also employ psychometricians to ensure
our test processes follow best practices in testing.
Our goal is to ensure that each candidate
receives a fair opportunity to demonstrate their
skills as a provider.
JEMS: The National Registry recently
issued new requirements for continuing
education (CE). Can you explain the CE
requirements to clarify what they mean to
an EMT or paramedic?
Dawson: We’re in the final stages of imple-
menting the new CE requirements across the
country, and most states are already using them.
There are fewer hours required, but more specific
content requirements for continuing education.
The new CE totals are 40 hours for EMTs,
50 hours for AEMTs and 60 hours for para-
medics (compared to 72 hours for all levels in
the traditional model).
Content requirements are defined for each
level based on the current medical evidence,
which can be found on the National Regis-
try website.
It’s always a challenge to stay up-to-date, so
we provide training officers with sample mate-
rials that can be used in their lesson plans.
Of course, this information must be tailored
to local protocols and issues, but references, out-
lines and objectives are provided as a resource.
Also, the National Registry website has a per-
sonal certification site for registrants, including
a transcript for CE.
The site stores a lifetime record of education
that can be applied in many ways, including cer-
tificates and descriptions for each course, which
makes the recertification application and audits
much quicker and easier.
We also released our first National Registry
iOS app in April, allowing EMS professionals
to easily track their EMS education and recer-
tification from their phone.
JEMS: What are some of the advantages of
being certified by the National Registry?
Dawson: Achieving National Registry certifi-
cation makes you eligible, in part, for licensure
in almost all states at some level, and is required
for licensure in 46 states at some level.
As a profession, National Registry certifi-
cation places EMS professionals “in step” with
virtually all other U.S. health professions that
are nationally certified and helps to advance the
EMS profession and protect the public.
National Registry certification isn’t just
about getting a card and a job, it demonstrates
that you’ve met and continue to meet rigor-
ous national standards for competency in the
EMS profession.
It also demonstrates to employers that you

INTRODUCING have a certain level of competence and that you’re

continually learning. It allows for more flexibility
THE NEW in terms of job options and crossing state lines.
UNIT 156
BIG MAN SEATING JEMS: Is there anything you’d like to add?
WITH COIL SEAT
Dawson: Recently, I looked at the top shelf of
the bookcase in my office and saw a gavel that
$725
....... was donated to the National Registry by Dr. J.D.
ugger
Wall nH-rocker 3D x 4
8H Farrington, Chair of the Board, from 1971–75.
no M (4 5W X 4 1D X 21H) Farrington is known as the “Father of Modern
56 B X2
UNIT 1 seat (24W -90-21
n S KU#156 90-17 EMS,” and he served the National Registry
row 56-
Dark B wn SKU#1 during its formative stages.
ro
Light B
My thoughts then turned to another
EMS legend and our building’s namesake,
Rocco Morando. Rocco was on a task force that
created the first EMT-Ambulance program and
made recommendations that resulted in the
UNIT 156 BM – The New creation of our organization (where Rocco also
and Improved Sentinel served as the first executive director).

AMERICA
AM
AMERICA STR
MERICA S
STRONG
RON
RO
RONG
ONG As I reflect on our history, I’m overwhelmed
by the passion and foresight of the National
Call Toll Free: Registry’s creators, and I’m inspired by their

888-380-2345 mission to improve prehospital care through-

out our nation.
Visit Our
Website To See
firestationoutfitters.com After my brief tenure as interim executive
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Sofas, Loveseats committee, I’m confident that the Board, the
& Chairs Furniture for all Firehouse & EMS applications:
recliners, day rooms, administration areas, equipment staff and the next executive director will con-
tinue this long-standing commitment. JEMS
For more information, visit JEMS.com/rs and enter 7.
14 JEMS | JUNE 2018 www.JEms.com

1806JEMS_14 14 5/14/18 7:57 AM


SIGNING OFF
PCR signatures are an essential part of patient care,
accountability & compliance
By Stephen R. Wirth, Esq., EMT-P
T
he patient care report (PCR) is the offi-
cial medical and legal record of your
contact with the patient. One of the
most important elements of a complete PCR
is the provider’s signature. Why? You’re pro-
viding professional medical care to the patient!
An accurate and complete PCR signed by
the caregiver completing the report is an essen-
tial part of that patient care.
Signing off on the PCR is also necessary to
have a complete medical and legal record of the
patient encounter, and the PCR becomes part
of the patient’s records in the hospital.
Your signature can be handwritten as part of
a paper report, or the report can be signed elec-
tronically. Most electronic PCR solutions have
effective ways of capturing your actual digital
signature with a stylus, or your typed name as
an electronic signature.
Electronic signatures will suffice as long as
there are proper login and access controls so
that it can be verified that your digital name
in the signature block of the report means you
personally signed the PCR.
Your signature must also include your printed
name and your credentials or certification level.
That should appear immediately under the
signature line.
This is especially important when the signa-
ture of the person completing the report is illeg-
ible. It also helps to ensure continuity of care,
and that the assessment and treatment was pro-
vided by properly certified EMS practitioners in
accordance with your state’s EMS laws.
Documentation of credentials identifies the
level of certification of the provider and helps
verify the that the crew and vehicle require-
ments are met for the respective level of service
provided (i.e., ALS vs. BLS).
In a nutshell, signing the PCR and docu-
menting your credentials helps ensure com-
pliance with legal and ethical requirements.
One of the most common questions we get
www.jems.com
1806JEMS_15 15
when teaching EMS documentation is, “If I’m
the primary caregiver completing the PCR, do
the other crew members need to sign it?” Or,
“Does the EMS law in our state require that
all crew members sign the PCR?”
In most states, the EMS laws don’t expressly
state that all crew members must sign the PCR.
Usually, laws require the primary caregiver
to complete the PCR. However, having all crew
members sign the PCR is a standard for EMS
documentation that should be followed for
three primary reasons.
RESPONSIBILITY
First, Medicare and other payers require that
those who provide services to the patient must
sign for those services.
Specifically, the Medicare Program Integ-
rity Manual, chapter 3, section 3.3.2.4 states,
“Medicare requires that services provided/
ordered/certified be authenticated by the per-
sons responsible for the care of the beneficiary.”
Even if you’re the designated “driver” on the
call and weren’t the primary caregiver, you were
still involved in the assessment and, to some
extent, are responsible for the care of the patient.
You’re responsible for the care you provided
to the patient—even if you simply obtained
vital signs or helped lift and move the patient.
This requirement also makes good sense.
Since we’re providing medical care, everyone
involved with the patient must be accountable
for the care we’re providing—lives are at stake!
TRANSPARENCY
Second, it’s simply good medical care for all
crew members to sign the PCR. Healthcare is
all about accountability and transparency. Even
if you’re not the primary care provider, you par-
ticipated in the patient encounter. When pro-
viding medical care, everyone involved with
the patient must be accountable for the care
they provide, and all crew members should
PRO BONO
EMS LEGAL TIPS & ADVICE
sign the PCR if you want to call it a complete
medical record.
FRESH EYES
Third, it’s a good “check and balance” for all
crew members to sign. When you sign the
PCR, you’re obligated to review it. Having
more than one set of eyes on the report helps
tremendously in reducing errors and omissions
in documentation.
For example, on a busy shift, a crew member
who wasn’t the primary caregiver may pick up
on an omission in documentation when review-
ing it (e.g., the failure to document that oxygen
was administered).
Quality assurance starts with providers
checking each other’s work, including the PCR
documentation. The earlier those errors are
picked up, the better—and the more promptly
reimbursement can be sought for your services.
Requiring that all crew members review and
sign the PCR is a best practice for ensuring that
you have a complete and accurate medical and
legal record of the patient encounter.
The bottom line is that legibly signing your
patient care reports, including your printed
name and credentials, is a fundamental standard
of care for PCR completion and an essential
part of being a healthcare professional. JEMS
Stephen R. Wirth, Esq., EMT-P, is an EMS
attorney and founding partner of Page, Wolf-
berg & Wirth, which represents EMS agen-
cies throughout the United States. He’s one
of the nation’s leading EMS attorneys and
one of central Pennsylvania’s first paramedics. He’s worked
in all aspects of EMS and the fire service in a variety of edu-
cational and leadership positions.
Pro Bono is written by the attorneys
at Page, Wolfberg & Wirth, The
National EMS Industry Law Firm.
Visit the firm’s website at www.pwwemslaw.com or find them
on Facebook, Twitter or LinkedIn.
jUNe 2018 | JEMS 15
5/14/18 7:57 AM
 CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BROKEN HEART
A rare diagnosis for chest pain patient
By Brendan Mulcahy, DO, PA-C, NRP; Haley Delligatti, BS, NRP & Talo Capuzzi, NRP
A
n ALS crew is dispatched for a
60-year-old male in cardiac arrest.
On arrival, the crew finds the patient
apneic, pulseless and cool to the touch with
obvious signs of death.
The patient’s wife is visibly distraught and
unable to present a detailed history to the
crew. The patient is confirmed asystolic on
the monitor and the crew pronounces him
dead on arrival. The crew leaves the scene and
returns to service.
Shortly after returning to service, the crew
is dispatched to the same address, this time
for a 60-year-old female complaining of chest
pain. It’s the wife of the decedent.
On arrival, the crew finds the woman in
obvious distress over the loss of her husband.
She describes suffering a sudden onset of
crushing chest pain. The pain was retroster-
nal and did not radiate. She describes the
pain as pressure-like, rating it a 5 on a scale
from 1–10.
The woman denies feeling any associated
shortness of breath, nausea, vomiting, abdom-
inal pain, lightheadedness, dizziness, fevers
and recent illness.
Her past medical history is significant for
back pain, arthritis and diabetes. Physical exam
Figure 1: 12-lead ECG showing anterio-lateral ST-segment elevation
16 JEMS | JUNE 2018
1806JEMS_16 16
reveals an emotionally distraught 60-year-
old female.
The crew next performs a complete cardiac
workup on the patient. Her initial vitals are a
pulse of 100, blood pressure 190/100 mmHg,
oxygen saturation of 93% on room air, and
her respiration rate is 24 and non-labored.
Her lungs are clear to auscultation bilaterally.
There’s no jugular vein distension or periph-
eral edema noted.
The patient is given 324 mg of aspirin. A
12-lead ECG is obtained (Figure 1); it reveals
anterio-lateral ST-segment elevation. (See
Figure 1.)
Two large-bore IVs are placed, followed
by administration of a spray of nitroglycerin,
which provides minimal relief.
As per protocol, the catheterization lab is
activated and the crew initiates transport with-
out delay to the hospital. During transport,
two more sprays of nitroglycerin are admin-
istered, and the patient’s vitals remain stable.
On arrival to the ED, the patient is briefly
evaluated and is then taken quickly for left
heart catheterization.
Heart catheterization reveals clear and
open coronary circulation with moderate left
ventricular dysfunction with left ventricular
wall motion abnormalities. A transthoracic
echocardiogram reveals an ejection fraction
of 55–74% and apical ballooning.
The patient is diagnosed with takotsubo
cardiomyopathy and subsequently transferred
to the cardiac care unit (CCU).
After a three-day uncomplicated stay in the
CCU, the patient is well enough to be dis-
charged home with a prescription for metop-
rolol and lisinopril.
DISCUSSION
Takotsubo cardiomyopathy, also called “broken
heart syndrome” or “stress-induced cardiomy-
opathy,” was first studied in Japan in 1991. The
word “takotsubo,” which means octopus trap,
was used by the Japanese to describe the car-
diac anomaly seen in the disease, as it resem-
bled the pot used to collect octopus.1
Despite thousands of cases reported since
the early 1990s, there’s still no clear and deci-
sive cause to this condition. Some of the more
common speculations include stress hormones,
microvascular spasm, focal myocarditis and
cellular level muscle changes.2
In the United States, the disease is more
common in females with roughly a 9:1 female
to male ratio.3 The clinical presentation is
characteristically similar to that of acute cor-
onary syndrome, and there’s typically a signif-
icant stressful event that precedes the onset
of symptoms.
12-lead ECG is often consistent with an
anterior MI, while cardiac enzymes can be
slightly elevated and return to normal quickly.
Diagnosis of takotsubo cardiomyopathy can
be made with heart catheterization and trans-
thoracic echocardiography. Coronary angiog-
raphy is performed to rule out acute coronary
syndrome. Most patients will have a loss of
motion at the apex and an apical balloon-
ing pattern—the visible sign behind the
syndrome’s name, because the enlarged left
ventricle takes on the shape of the octopus
pot.4,5 (See Figure 2.)
www.JEms.com
5/14/18 7:57 AM
 There are no evidence-based guidelines for
the treatment of takotsubo cardiomyopathy.
Treatment is usually supportive, with physi-
cians often ordering standard heart failure
medications such as beta-blockers, ACE inhib-
itors and diuretics. Aspirin may also be given
to patients who also have atherosclerosis.6
About 10–15% of people who’ve experienced
takotsubo cardiomyopathy will have another
episode, and, for those affected a second time,
the stressful event can be completely different.
CONCLUSION
Prehospital providers must always remember
to do a full cardiac assessment for patients with
unexplained causes of chest pain. Takotsubo
cardiomyopathy is a rare cardiac anomaly, but
affected patients may be at risk for develop-
ment of dysthymia or heart failure,6 and require
prompt medical attention. JEMS
REFERENCES
1. Bielecka-Dabrowa A1, Mikhailidis DP, Hannam S, et al. Takotsubo
cardiomyopathy: The current state of knowledge. Int J Cardiol.
2010;142(2):120–125.
TM
FIRE & EMS BLOGGERS
ALL IN ONE NETWORK!
www.fireemsblogs.com
For more information, visit JEMS.com/rs and enter 9.
www.jems.com
1806JEMS_17 17
2. Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s emer- Figure 2: Apical ballooning pattern
gency medicine: Concepts and clinical practice, 8th edition. Else- seen in takotsubo cardiomyopathy
vier/Saunders: Philadelphia, 2014.
3. Dorfman TA, Iskandrian AE. Takotsubo cardiomyopathy: State-
of-the-art review. J Nucl Cardiol. 2009;16(1):122–134.
4. Komamura K, Fukui M, Iwasaku T. Takotsubo cardiomyopa-
thy: Pathophysiology, diagnosis and treatment. World J Cardiol.
2014;6(7):602–609.
5. Castillo Rivera AM1, Ruiz-Bailén M, Rucabado Aguilar L. Takot-
subo cardiomyopathy—A clinical review. Med Sci Monit.
2011;17(6):RA135–RA147.
6. Takotsubo cardiomyopathy. (n.d.) British Heart Foundation. Normal heart shape after
Retrieved March 16, 2018, from www.bhf.org.uk/heart-health/ the left ventricle contracts
conditions/cardiomyopathy/takotsubo-cardiomyopathy.
Brendan Mulcahy, DO, PA-C, NRP, is a first-year emergency
medicine resident at Allegheny General Hospital in Pittsburgh.
He’s also a prehospital physician extender with Ross/West
View EMS-Rescue in North Pittsburgh.
Haley Delligatti, BS, NRP, recently received her BS in emer-
gency medicine from the University of Pittsburgh School of
Health and Rehabilitation Sciences. She’s also a paramedic with
Ross/West View EMS-Rescue in North Pittsburgh. Takotsubo cardiomyopathy
Talo Capuzzi, NRP, is a paramedic and crew chief with Ross/ Left ventricle is enlarged and resembles
West View EMS-Rescue in North Pittsburgh. a Japanese pot used to trap octopus
The name in Safety, Rescue and Survival.
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jUNe 2018 | JEMS 17
5/14/18 7:57 AM
 SIMULATION SUCCESS
DESIGNING & BUILDING EFFECTIVE SCENARIOS
PEOPLE AS PATIENTS
Considerations when using standardized patients in EMS simulation
By Timothy Whitaker, BS, CHSE, CHSOS, EMT-P; Jennifer McCarthy, MAS, NRP, MICP, CHSE & Andrew E.
Spain, MA, NCEE, EMT-P
T
he use of live humans as part of a
simulation activity enhances realism
by allowing a more realistic commu-
nication exchange that includes nonverbal
cues. EMS has long used “actors” to
portray an illness or injury during
a simulation.
Many of us can remember our
paramedic school instructors often
stepping in to play the part of the
patient. Embracing standard lan-
guage from the Healthcare Sim-
ulation Dictionary, actors come in
many forms based on the need of
the simulation activity: embedded
participant, role player, simulated
person and standardized patient.1
Standardized pateints are defined as “a
person who has been carefully coached to
simulate an actual patient so accurately
Simulation activities with standardized patients are typically more challenging to design, but using them can
significantly enhance realism. Photo courtesy EMSTA College
18 JEMS | JUNE 2018
1806JEMS_18 18
that the simulation cannot be detected by
a skilled clinician.
In performing the simulation, the stan-
dardized patient presents the gestalt of the
Standardized patients are
a valuable tool for the
EMS educator to utilize
to enhance learning.
patient being simulated; not just the history,
but the body language, the physical findings,
and the emotional and personality charac-
teristics as well.”1
The addition of the integrated out-of-
hospital scenario to the National Registry
of EMTs Paramedic Psychomotor Exam
has increased the need for and use of stan-
dardized patients in EMS simula-
tion activities.
This column will focus on the
best practice of using standardized
patients in simulation activities that
will improve validity and reliability.
HISTORY & CHALLENGES
The use of standardized patients in
medical education programs can be
tracked back to the 1960s.2 Over
the years, standardized patient pro-
grams have been refined to provide better
safety for the standardized patient and a more
accurate experience for the participants.
Standardized patients are primarily used in
medical schools to evaluate common com-
petencies such as communication, clinical
reasoning and diagnosis.3
They are also often used in summative
objective structured clinical exams, which
are used when determining the progression
of a medical resident.
Today, healthcare education is seeing a
broader application of standardized patients,
as the importance of assessing human fac-
tors, crisis communication and patient dia-
logue has become invaluable for improving
patient safety.
Identifying the optimal way to integrate a
standardized patient into a simulation activ-
ity isn’t an easy task. Simulation activities
with standardized patients are typically more
challenging to design due to the numerous
variables that exist when using human par-
ticipants in a scenario.
The standardization of behaviors and
presentations that’s essential for valid and
reliable assessments is particularly tricky
www.JEms.com
5/14/18 7:57 AM
 given human nature—and the possibility
for extemporization (i.e., improvisation) by
the standardized patients.
As educators, it’s imperative that students
are provided with a fair, valid, and realistic
learning and evaluation environment.
Given the amount of research on the value
of SP use, embracing the evidence is the
next best step of our evolution in simula-
tion education.3
The Association of Standardized Patient
Educators (ASPE) has compiled the evi-
dence and has identified four domains of
best practice: 1) safe work environment;
2) case development; 3) SP training; and
4) program management.4
SAFE WORK ENVIRONMENT
This is achieved by developing policy, proce-
dures and standards that define expectations
related to standardized patient involvement
within the program.
Outlining clear parameters up front avoids
many issues, and more importantly, maintains
safety for all involved in the activity. General
policies should address the following (although
this is not necessarily a complete list): recruit-
ment, formal training, operations, assessment,
opting out, confidentiality, respect and qual-
ity assurance.
Once policies are established, recruitment
of the SP candidates can begin. standardized
patients can be recruited in a variety ways,
such as local theater groups, nearby EMS
agencies, drama clubs and civic associations,
to name just a few.
Using minors as standardized patients
should be done with caution because of
parental consent issues and the higher like-
lihood of exposing educators and programs
to legal risks. Further, the EMS environment
is probably not an ideal situation for them
to be exposed to.
CASE DEVELOPMENT
As with other simulation activities, utilizing
standardized patients begins with a needs
analysis and identifying the learning objec-
tives of the activity. The case design must
be medically probable, reproducible, allow
for ample time to evaluate the interaction
with the standardized patient, and be appro-
priate for the level of learner completing
the activity.
The standardized patient should be given
adequate time and training to assimilate
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1806JEMS_19 19
the role.
There should be a pilot test of the activ-
ity, allowing educators to ensure the stan-
dardized patient is portraying and conveying
the proper information reliably, and that this
portrayal is reproducable for each and every
learner encounter.
It’s imperative to provide the standard-
ized patient with a well-designed script that
includes cueing for the standardized patient,
as they may have different life experiences
or views than what needs to be portrayed.
Faculty colleagues may be a great resource
to rehearse the simulation activity, where
they can assess the validity and reliability of
the standardized patient by looking at the
activity through the “eyes” of the learner.3
TRAINING
Before standardized patients can participate
in an activity, they need to be trained. Simply
finding the first person who’s available and
giving them a script the day of the activity
is certainly not best practice, and will result
in poor validity or reliability of the learning
activity or assessment. Training is paramount
if the assessment is a summative (i.e., pass/
fail) situation.
Training the standardized patient on real-
istic presentation and guiding them so that
they avoid “overacting” is important for clin-
ical decision-making progression.
Community colleges and universities that
offer health profession education have med-
ical resource librarians who can be a great
resource to assist standardized patients with
research related to a realtistic presentation
of a specific illness or injury.
If a program is capturing assessment
information from the standardized patient,
or if the standardized patient will be partic-
ipating in the debriefing, training to appro-
priately and accurately assess and provide
feedback during debriefing also needs to
be provided.
PROGRAM MANAGEMENT
Program management actually begins with
establishing the policy and procedures, but
then evolves to include quality improvement
and engaging with content experts to assist
with the development of your standardized
patient program.
Collecting feedback from not only the
standardized patient, but also the learners,
can be invaluable in identifying areas for
improvement. This feedback should help
refine and improve the standardized patient
performance, program performance and
learner experiences.
CONCLUSION
When deployed using these best practices,
standardized patients are a valuable tool for
the EMS educator to utilize to enhance the
learning and evaluation process.
It’s essential for standardized patients and
learners to be embedded in a safe learning
environment and that the scenario can be
reproduced reliably multiple times.
This is especially true when the simula-
tion activity is part of a summative assess-
ment, where the stakes are high, and passing
might mean the difference in whether or not
the learner will graduate from a program or
pass the National Registry exam. JEMS
REFERENCES
1. Lopreiato JO, editor. (June 2016.) Healthcare simulation
dictionary, 1st edition. Society for Simulation in Healthcare.
Retrieved April 22, 2018, from www.ssih.org/dictionary.
2. Palaganas JC, Maxworthy JC, Epps CA, et al., editors: Defin-
ing excellence in simulation programs. Wolters Kluwer:
Philadelphia, 2015.
3. Levine AI, DeMaria Jr S, Schwartz AD, et al., editors: The
comprehensive textbook of healthcare simulation. Springer:
New York, 2013.
4. Lewis KL, Bohnert CA, Gammon WL, et al. The Associa-
tion of Standardized Patient Educators (ASPE) standards
of best practice (SOBP). Adv Simul (Lond). 2017;2:10.
Timothy Whitaker, BS, CHSE, CHSOS, EMT-P,
is a clinical educator at CAE Healthcare. He’s an
experienced simulation educator credentialed
by the Society for Simulation in Healthcare as
a Certified Healthcare Simulation Educator
(CHSE) and a Certified Healthcare Simulation Operations Spe-
cialist (CHSOS). Contact him at timothy.whitaker@cae.com.
Jennifer McCarthy, MAS, NRP, MICP, CHSE,
is a founding member, associate professor and
director of the Paramedic Science Program at
Bergen Community College in Lyndhurst, N.J.
She’s a national presenter at both EMS and
medical simulation conferences and has a passion about the
use of medical simulation to advance learning within the EMS
profession. You can reach her at jmccarthy@bergen.edu.
Andrew E. Spain, MA, NCEE, EMT-P, is the
director of accreditation and certification for
the Society for Simulation in Healthcare. He’s
been a paramedic for more than 20 years and
is a nationally certified EMS educator. You can
reach him at aspain@ssih.org.
jUNe 2018 | JEMS 19
5/14/18 7:57 AM
 STREET SCIENCE
CONVERSATIONS ABOUT EMS RESEARCH
THANKS FOR THE FEEDBACK
How often do providers receive feedback about their care?
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
THE RESEARCH
Cash RE, Crowe RP, Rodriguez SA, et al. Dis-
parities in feedback provision to emergency
medical services professionals. Emergency
Care. 2017;21:773–781.
THE SCIENCE
This study comes from data obtained
through the National Registry of EMT’s
LEADS project.
A survey was delivered with the registra-
tion packet for EMTs and paramedics. The
objective was to determine how frequently
EMS providers are given feedback on their
care, the type of feedback received and how
they received it.
A total of 15,766 surveys were reviewed,
with 69.4% of respondents reported receiving
some form of feedback in the 30 days pre-
ceding the survey, 54.7% receiving specific
feedback on the medical care they provided.
Receiving feedback occurred more often for
paramedics, EMS providers with fewer years
of service, those that worked for hospital-
based agencies, air medical services, and those
with higher weekly call volumes.
Feedback was most commonly provided
verbally (94.8%) followed by email (35.1%),
written (18.5%), and text message (16.3%).
Feedback was received most commonly
from a partner or crew member (70.9%),
supervisor (59.6%), receiving facility staff
(57.4%), and quality improvement officers
(42.6%). The medical director was the least
common source of feedback at 20.6%.
The conclusion highlighted the concern
that almost one-third of respondents hadn’t
received any feedback.
They further noted the significant dis-
parity in sources and modalities used to
provide feedback.
MEDIC WESLEY COMMENTS
One of my favorite bosses was a nurse
manager in the ED who had a sign in
20 JEMS | JUNE 2018
1806JEMS_20 20
her office that said, “Catch people doing
something right.”
Feedback to EMS professionals from peers,
hospital staff, and medical directors is the
opportunity to let providers know when they
do something right.
In my career, there weren’t many times
I walked out of work at the end of the day
wondering if my care was complete, correct,
or all-out wrong.
I’m one of those people who dogged the
staff, or my medical directors, for the answer.
And I learned from it.
But what about those providers who don’t
know what they don’t know? They walk away
thinking all’s well, and unless it’s a negative
QA contact, they rarely hear otherwise.
Feedback is absolutely essential, not only
for improvement, but also to encourage the
desire to learn and to develop relationships
with the other professionals who receive
our patients.
When open communication and closed-
loop feedback occurs, it builds knowledge
and confidence.
This study suggests that we aren’t doing a
great job of mentoring providers.
I’m going to give “props” to Doc Wesley.
When providers call at all hours of the day,
I have the opportunity to hear his side of the
medical control call.
I listen briefly before nodding back off,
but my favorite thing to hear is when he says,
“What do you think?”
This is usually followed by, “I agree, good
decision. Flag it for review and I will look it
over and we can talk about it.”
That’s feedback. That’s mentoring, and
mentoring is what’s needed to improve
patient care.
DOC WESLEY COMMENTS
Feedback on patient outcomes and the quality
of care is vital to professional development.
However, that feedback must come through
proper channels and not violate protected
health information (PHI).
I wonder how many of these respondents
got their feedback like this, “Hey, remem-
ber that guy you transported to the hospital
with a stroke yesterday? We stopped by the
nursing station and looked at his chart and
he did have a stroke. Looks like it was a bad
one, and the family is making him comfort
care only. But hey, the nurses said you did a
great job!”
There are rules to be followed and processes
in place to obtain this type of information.
Once you drop a patient off and submit
your run sheet, you have no legal authority
to examine their medical record or ask some-
one else to do so.
Hospitals have received significant fines
and sanctions for violating PHI.
I worry about how much information was
communicated in the email and text messages
that provided their feedback.
I get it; we need to give feedback, but we
need to be sure we’re doing it correctly.
The fact that the medical director was the
least most common source of feedback is prob-
ably a reflection of the fact that physicians are
well-versed in what they can and can’t disclose
under the peer review statute.
I and my QA specialist have a separate email
template that specifically states the material
contained is confidential and being provided
in accordance with state statute.
And finally, the “props” go to Medic Wes-
ley for her endless support and patience. JEMS
Keith Wesley, MD, FACEP,  FAEMS,  is the
medical director for HealthEast Medical
Transportation in St. Paul, Minn., and United
EMS in Wisconsin Rapids, Wis. He can be
reached at drwesley@charter.net.
Karen Wesley, NREMT-P, is a retired para-
medic, police officer and SWAT medic, and
an EMS education consultant. She can be
reached at admkaren22@hotmail.com
www.JEms.com
5/14/18 7:58 AM

BUILDING RESILIENCE
An update from the EMS Alliance on Resiliency
By Members of the EMS Alliance on Resiliency
T
his is the first quarterly report on the
work of members of the EMS Alliance
on Resiliency, a coalition of concerned
organizations and experts who have banded
together to develop and implement programs
designed to reduce emergency personnel stress
and suicide. There are currently 37 members
from North America and Australia, with others
signing on as our mission and its message grows.
NEMSMA’S GLOBAL EFFORT
The National EMS Management Associa-
tion’s (NEMSMA) Resiliency Program Devel-
opment Team has been working diligently
to advocate for national standards for stress
management programs for EMS institutions.
In March, a group of 10 representatives
from NEMSMA’s practitioner mental health
and well-being committee participated in
a three-day Global Paramedic Leadership
Mental Health Summit in Warwick, England.
Each participating country at the summit
(United States, United Kingdom, Australia,
Canada and New Zealand) shares the common
factor of having a large number of EMS prac-
titioners who experience mental health con-
cerns, continuing negative stigma and a lack of
resources, research and tools to intervene and
minimize mental illness and suicide. Delegates
shared the programs and tools they currently
have in place and also those in development.
Canada, the U.K. and Australia seem to be
far more advanced than the U.S., with gov-
ernment oversight and funding at the federal
level. These countries differ from the U.S. in
that they view EMS as a highly respected pro-
fession, one that requires a higher level of edu-
cation, such as Bachelor’s or Master’s degree.
Canada: A new entity, the Canadian Insti-
tute of Public Safety Research and Treatment
(CIPSRT) has categorized three different
levels of stress: 1) critical stress; 2) organiza-
tional stress; and 3) operational stress. Their
website, www.cipsrt-icrtsp.ca, has an anon-
ymous assessment tool which compares a
www.jems.com
1806JEMS_21 21
IMPROVING MENTAL HEALTH & WELL-BEING
respondents score to others in the same public
safety field. The website also hosts additional
articles and resources.
CIPSRT is currently working on a new
project that aims to survey the prevalence of
operational stress injuries among public safety
personnel. Results are expected to be available
in Summer 2018.
United Kingdom: Overall, the U.K. has
adopted a holistic and collaborative approach
for training, advice lines, research, suicide pre-
vention and self-engagement.
One technique used is impact monitoring,
which is a mandatory yearly evaluation that
looks at how the job has changed the provider
mentally. Evaluation sessions last approximately
one hour and include a conversation, rather
than counseling.
In addition to impact monitoring, a
EMS Alliance on Resiliency
• American Ambulance Association
• Philip Callahan, PhD
• Centura Health
• Code Green
• Commission on the Accreditation of Ambu-
lance Services
• EMS World
• EMS1
• First Watch
• Frontline Program
• Georgia Office of Emergency Medical
Services/Trauma
• Image Trend
• International Academies of Emergency
Dispatch
• International Association of Fire Chiefs
• International Association of Fire Fighters
• International Critical Incident Stress Foundation
• Journal of Emergency Medical Services (JEMS)
• Michael W. Marks, PhD
• National Association of EMTs
RESILIENCY REPORT
roundtable approach called “Swartz Rounds”
involves paramedics, nurses and team members
who provide patient care from start to finish.
MIND is a charitable organization that
funds mental wellness programs in the UK.
Their first responder wellness program, “Our
Blue Light” takes an integrated approach.
Efforts have included creating peer sup-
port “champions,” organizational leadership
training and provider education. Momentum is
building around the year-old program; however,
there hasn’t yet been any research to empirically
demonstrate its effectiveness.
Australia: Australia has had mental health
assistance for more than 30 years, implement-
ing processes that have been successful in other
countries. This has resulted in Australia being
the only country at the summit that has sig-
nificantly minimized, if not erased, the stigma
• National Association of EMS Educators
• National Association of EMS Physicians
• National Association of State EMS Officials
• National EMS Management Association
• National Fallen Firefighters Foundation
• National Highway Traffic Safety Administra-
tion OEMS
• National Registry of Emergency Medical
Technicians
• National Volunteer Fire Council
• Paramedic Chiefs of Canada
• Paramedics Australasia
• Reviving Responders
• Safe Call Now
• Strub Caulkins Center for Suicide Research
• Texas Office of EMS/Trauma System
• The Fit Responder
• The Paramedic Foundation
• U.S. Department of Homeland Security
• U.S. Military
• ZOLL
jUNe 2018 | JEMS 21
5/14/18 7:58 AM
 RESILIENCY REPORT
around mental illness and wellbeing in the workplace.
Queensland Ambulance Service (QAS) has a wellness support pro-
gram called Priority One, that’s fully integrated into the EMS culture and
is centered on the concept of salutogenesis. This is an approach focusing
on factors that support human health and well-being vs. factors that cause
disease. The program works to maximize an individual’s post-traumatic
growth following critical incident stress or cumulative stress.
Priority One has developed effective ways for providers to access ser-
vices and a robust education/communication component, and fosters a
high degree of connectedness between providers and the organization.
Independent evaluation of Priority One has shown that the program
is highly effective. QAS is currently concluding a research study examin-
ing the prevalence of providers who experienced post-traumatic growth
following a traumatic event.
United States: Developing and implementing industry-wide resources
is much more challenging in the U.S., where more than 21,000 EMS
agencies operate relatively independently.
The coalition of international agencies at the summit agreed that it’s
important to move forward with a unified command for mental health
resilience vs. disjointed programs and processes.
Although resources and funding is often limited, the group agreed that
it doesn’t cost anything for supervisors and peers to ask EMS providers,
“Are you OK?” The human connection of letting someone know that
support is there when needed should be used and expressed more often.
Participating countries and organizations pledged to continue to
work together to build resilience, eliminate stigma, promote self-care,
share effective programs, and intiate a holistic approach that includes
mental, physical and spiritual avenues.
Lastly, the group agreed to offer continuing education opportuni-
ties around mental health and focus more on the topic when it’s cov-
ered during the initial certification as well as recertification processes.
For more on this global effort, read the May Management Focus column, “Global Resilience Effort:
New international alliance addresses key concerns in EMS” by Vincent D. Robbins, FACPE, FACHE.
ImageTrend’s CrewCare app provides insight on first responder stress and asso-
ciated factors that may play a role in stress, anxiety, burnout, depression, PTSD
and suicide.
22 JEMS | JUNE 2018
1806JEMS_22 22
NVFC SHARES THE LOAD
The National Volunteer Fire Council (NVFC) has partnered with
American Addiction Centers to offer a free, confidential Fire/EMS
helpline (888-731-3473) that firefighters, EMS providers and their
families can call at any time for help with a behavioral health issue.
The program, called “Share the Load,” provides tools, resources
and training to help individuals and departments proactively address
behavioral health.
In 2017, there were 1,073 calls to the helpline, an increase of 26.5%
over the previous year. The NVFC also released the third issue of the
program’s newsletter, the Helpletter. Resources, training and tools to
address behavioral health issues and implement a department pro-
gram can be accessed at www.nvfc.org/help.
For more information on the National Volunteer Fire Council’s Resiliency efforts, contact
Dave Finger at dfinger@nvfc.org.
IMAGETREND’S MENTAL HEALTH APP
ImageTrend’s commitment to first responder mental health awareness
has resulted in the recent launch of CrewCare, a free mobile app for
any first responder. ImageTrend is a company with many experienced
EMS and firefighter personnel on staff, giving a great appreciation for
the mission of the EMS Alliance on Resiliency and JEMS.
CrewCare, introduced in February 2018 at the EMS Today Con-
ference, provides insight on first responder stress and associated fac-
tors that may play a role in stress, anxiety, burnout, depression, PTSD
and suicide.
The app provides users with a confidential way to look at the stresses
they are facing not only on the job, but in their own lives related to
family, finances, sleep, mental health, physical health and more.
Users are able to receive instantaneous feedback on their engage-
ment, mood and associated activities. Through charts and graphs,
users can see an overall view of their stress over time, as well as
how they may compare to other users. The app also provides links
to relevant topical resources and national mental health support
and crisis contacts.
CrewCare also offers organization-level options that allow person-
nel to provide anonymous feedback that can recognize department
stress and gain insight to inspire positive change.
The organization has the ability to provide local employee assistant
programs/support and crisis contacts, department specific questions
for the crews and receive an optional report that shows an organiza-
tion’s strengths and weaknesses related to stress.
At the industry level, CrewCare will be using aggregated, non-iden-
tifiable data analyses to create an overall understanding into how we
can do better at all levels of first responder mental health. The breadth
of information gathered can help us all take action to help reduce stress
and improve career satisfaction.
After just seven weeks of its launch date, close to 1,000 individuals
downloaded and began using the free app, a sign that this resource is
an effective and welcome tool for stress management and reduction.
CrewCare is available from the Apple App Store and Google Play as a
free download. To learn more about CrewCare, visit CrewCareLife.com.
For more information on ImageTrend’s resiliency efforts, contact Business Development
Manager David Zaiman at dzaiman@imagetrend.com.
www.JEms.com
5/14/18 7:58 AM
 STRUB CAULKINS MAKES STRIDES
Since the inaugural meeting of the EMS
Alliance on Resiliency, the Strub Caulk-
ins Center for Suicide Research has either
completed or made significant progress on
the following research, articles and presen-
tations and projects.
Research: Along with co-researcher Dar-
iusz Wolman, PhD, of Eastern Kentucky
University, Chris Caulkins conducted a sur-
vey of every EMS provider in the state of
Minnesota. The analysis is now complete,
and it’s anticipated the resulting informa-
tion will yield several publishable papers.
Findings indicate that the rates of sui-
cidal ideation, planning, and attempts are
all significantly higher in the emergency
responder population.
The Center has also joined forces with
Reviving Responders to perform an inferen-
tial analysis on the results of their nationwide
EMS survey on EMS responder suicidality
and access to mental health resources.
Reviving Responders has already pub-
lished their descriptive statistics, giving
a valuable window into the nature of the
problem. This partnership will help make
an already excellent piece of work an even
stronger study.
Articles: Three articles were published
in the first two 2018 editions of Minnesota
Fire Chief: The Heavy Psychological Toll on
Firef ighters, Response to Suicidal People and
Deaths by Suicide: Scene safety or stigma?, and
Suicidality and Disasters: An ante-, peri-, and
post-catastrophe look.
An article on psychological trauma and
suicide among EMS providers has also been
written and submitted to JEMS for future
publication.
Presentations: A presentation on psycho-
logical trauma and suicidality among EMS
providers was made at the EMS Time Crit-
ical Call Conference in Fergus Falls, Minn.,
in February 2018.
The night before the conference, Caulk-
ins stopped in to Oakes, N.D., where he
presented on suicide basics to the Oakes
Ambulance Service.
Also in February, Caulkins hosted an
online educational session called Suicidology
101 for those interested in learning about
the field in hopes of attracting more peo-
ple to the field of suicidology. There were
26 attendees from around the U.S., most of
whom were EMS professionals.
www.jems.com
1806JEMS_23 23
In March, Caulkins accompanied a group
of representatives sponsored by NEMSMA,
to the U.K. to present on suicidality among
EMS personnel.
In April, Caulkins presented research
results on rates of responder ideation, sui-
cide planning, attempts, access to means, and
suicide deaths at the American Association
of Suicidology Conference in Washington,
D.C. The next month, Caulkins presented
his research at the International Association
for Suicide Prevention Asian Pacific Con-
ference in New Zealand.
In February, Chris and board member
Brittany Miskowiec presented on suicidality
and delivered SafeTalk training to a team of
peer support volunteers for the MnFire Inti-
tiative—a non-profit dedicated to support-
ing firefirefighters with health issues relating
to cancer, heart disease, and mental health.
Projects: Caulkins has been actively
engaged with a NEMSMA work group in
drafting a resilience and resistance program
for EMS providers. The Strub Caulkins
Center for Suicide Research has accepted an
invitation to sit on the emergency responder
suicide prevention subcommittee of the
National Action Alliance for Suicide Pre-
vention. This is a public-private partnership
that’s federally recognized.
The Strub Caulkins Center for Suicide
Research, a non-profit 501(c)(3) organiza-
tion, is available for presentations or research
assistance on suicide and related phenomena.
For more information contact Executive Director Chris
Caulkins at c.caulkins@suicideresearch.org.
NEW BOOK & ONLINE TRAINING
At the EMS Today Conference in Febru-
ary, JEMS Editor-in-Chief A.J. Heightman,
MPA, EMT-P, announced several initiatives
to bolster the effort to define and address
the problem of stress and suicide.
Philip Callahan, PhD, a paramedic and
psychologist, worked with Michael Marks,
PhD, from the Veterans Administration, to
develop a semester-long resiliency class to
support high-risk combat veterans entering
the University of Arizona.
The three-credit class focused on 12 pos-
itive coping skills to build resilience and fos-
ter social support. They experienced great
success, with students making statistically
significant gains in resilience.
Following the success of the class, Marks
and Callahan coauthored First Response
Resiliency, a textbook and accompanying
workbook that’s been used by a number of
agencies.
Since its initial release, the 12 skills have
been compressed into eight in an effort to
reduce the complexity and training time.
Callahan developed a workbook for the new
format, and the compressed version showed
statistically significant gains similar to the
12-skill version.
Marks has recently completed a book on
first responder resiliency that will be avail-
able through JEMS/PennWell in Summer
2018. The book, titled Community of One:
Building Social Resilience, aims to reduce
training complexity that’s involved in teach-
ing the course, and seeks to more closely
involve the first reponder’s family. Experts
agree that a social support system is critical
to successful resilience, and family is most
often the primary element of a social sup-
port system.
Included with the book is a map of the
five coping skills that Callahan developed,
based on the 12 and eight-skill course.
Callahan is also working with JEMS
continuing education partner Medic-CE
to develop Beyond The Call: Mental Health
Awareness for First Responders an innovative
four-hour online training course where par-
ticipants will work on issues related to the
five resiliency skills: 1) belief; 2) persistence;
3) strength; 4) trust; and 5) adaptability.
Course participants will be partnered with
one another during the course; the idea being
that their partner will be part of a social
support system moving forward. Each of
the five skills will be explored by partici-
pants, one at time, by examining their own
real-life challenges.
Although most work will be done on the
participants’ own time, there will also be a
classroom component where participants
will meet online (anonymously) in real-time.
Led by an online facilitator, participants will
discuss their shared results and report on
how they used the skills.
The approach taken by the course is con-
sistent with evidence-based research as well
as the World Health Organization’s 2014
study on suicide reduction, which recom-
mended that developing a sound social sup-
port system and positive coping skills would
aid war veterans and emergency responders
in dealing with adversity. JEMS
jUNe 2018 | JEMS 23
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1806JEMS_24 24 5/14/18 7:58 AM


Lessons learned from the truck attack in
Berlin, Germany
By Johannes Kohlen, EMT-P & Klaus Runggaldier, PhD, EMT-P
I
t was a cold, dry winter’s evening at a
popular Christmas market at Breitscheid-
platz in Berlin, Germany on the night of
December 19, 2016. With the temperature
hovering just above freezing, residents and
visitors peacefully drank warm, mulled wine
as they huddled around market stalls next
to the Kaiser Wilhelm Memorial Church.
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1806JEMS_25 25
Nobody noticed the semi-trailer truck, stolen
earlier that night, as its driver made his way
from the direction of Zoologischer Garten
railway station and deliberately drove into
the crowd of holiday shoppers in the square
outside the church.
The incident, likely a terrorist attack,
injured 67 people, many critically, and 12
Injured persons are treated by first responders and
bystanders who provided initial first aid after a terror-
ist drove a truck into a crowd of people at a Christmas
market in Berlin. Photo courtesy Berliner Feuerwehr
people were killed. In the year since this attack
took place, deliberate attacks where vehicles
are used as lethal weapons have increased in
frequency and become a disturbing trend.
Last year, vehicles were used as weapons in
attacks in cities both large and small, in the
U.S. and abroad, including New York City,
Barcelona, Charlottesville (Va.), Stockholm,
Jerusalem and London—where there were
two attacks. Sadly, Germany can now lay
claim to experiencing two of these attacks,
after the driver of a delivery truck slammed
into a crowd of people in the city of Muen-
ster on April 7.
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5/14/18 7:58 AM
 VEHICLES AS WEAPONS
CHRONOLOGY OF THE ATTACK
At 8:02 p.m., the semi-trailer truck is delib-
erately steered into the walkway between the
stalls of the Breitscheidplatz Christmas mar-
ket. The first person to place a call 1-1-2, the
European emergency number, reports a traf-
fic accident on the other side of the square.
At 8:04 p.m., acting on the assumption that
there’s been a traffic accident and not a delib-
erate attack, the Berlin Fire Department dis-
patches one fire truck, one ambulance and one
emergency doctor vehicle, providing them with
the description for a standard traffic accident.
Additional people calling 1-1-2 describe
the event in more detail. Two of the callers, an
off-duty rescue service employee and an emer-
gency doctor, try to give dispatchers a clearer
picture of the scale of the events unfolding:
“Zoologischer Garten. Mass casualty inci-
dent. Several injured. Truck crashed into the
Christmas market outside the Waldorf Asto-
ria,” one of them says.
“Budapester Strasse, right?” the emergency
dispatcher asks, referring to Budapest Street.
“Exactly. Unfortunately, this isn’t a joke. I’m
afraid it’s serious. A truck—a big one—has hit
a crowd of people!”
26 JEMS | JUNE 2018
1806JEMS_26 26
At 8:07 p.m., the Berlin Fire Department
dispatches two additional fire trucks, five
ambulances, two emergency doctor’s vehi-
cles and one large equipment vehicle carrying
extra materials required to treat the injured at
large-scale incidents.
Commanding officers of the incident are
appointed, and include an organizational chief
of EMS, a senior emergency physician and an
experienced incident commander.
At 8:09 p.m., the dispatch center changes
the description of the alert to “mass casualty
incident (MCI). Threat situation—police.”
This alerts emergency personnel that there
may be an active threat when they arrive on
scene, and that they must adjust their tactical
approach accordingly.
It takes emergency personnel approximately
two minutes to get from the fire station on
Rankestrasse (i.e., Rank Street) to the loca-
tion of the incident at Breitscheidplatz square.
On arrival at the Weltkugelbrunnen (i.e.,
world fountain), a water feature which is
located about 492 feet (150 meters) away from
the incident, emergency personnel encounter
visitors peacefully drinking mulled wine while
visiting the Christmas market.
EMS personnel treat injured patients amidst the
trail of devastation left behind after a stolen trailer
truck plowed through the alleyway of the Christ-
mas market. Photo courtesy Berliner Feuerwehr
Other people rush toward them, alerting
them that the incident is on the other side
of the square.
At 8:11 p.m., emergency personnel arrive
on scene, where they see a heavily damaged
truck standing in the street.
An initial size-up of the scene, completed
by an officer from the Moabit Fire Depart-
ment, reveals there are many people injured
and a high probability of fatalities. He notes
the truck’s cargo: a load of steel parts.
The truck had entered the alley between the
stalls at a crosswalk, drove about 196 feet (60
meters) through the market, turned to the left
and returned onto Budapester Strasse, where
it finally came to a halt.
Several people are trapped under the truck
and show no signs of life. Bystanders had
already started providing first aid to those
who were injured.
Many of the stalls that form the Christ-
mas market have partially collapsed, and the
path between them is still visible. Stall light-
ing offers only dull illumination of the scene.
Emergency personnel begin identifying the
seriously injured, dead and dying. Medical care
becomes the top priority.
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 All firefighters are qualified to provide BLS
care at the EMT level, and many are paramed-
ics and able to provide ALS care.
Together with the bystanders already pro-
viding first aid, they begin treating injured
patients between the market stalls. Triage
squads categorize the wounded by marking
them with triage tags and then documenting
the tags in their logs.
Three lifeless bodies are identified as being
trapped under the truck, and rescuers fear
more of victims could be buried beneath the
partially collapsed stalls.
In addition to the stability of the remaining
stalls, emergency personnel also consider the
danger posed by gas escaping from cylinders In an ambulance staging area, EMS crews are organized and ready to transport patients as they’re assigned
powering the now-damaged food stalls as well for transport. Photo courtesy Berliner Feuerwehr
as the position of the truck in the poor lighting.
The dispatch center and the on-site inci- As the number of fire department resources police cordon.
dent commanders are also concerned about responding to the incident continues to rise, At 8:45 p.m., Provincial Fire Protection
the possibility of a second strike by additional the voluntary fire department is requested to Director Wilfried Gräfling assumes leader-
attackers. In cases where there is still a poten- report for duty. Other off-duty professional ship of incident command.
tial threat, Berlin’s emergency response pro- firefighters report to their departments, even The technical rescue unit of the Charlot-
cedures call for the commander of the fire without being formally alerted. tenburg Nord Fire Department is alerted to
department and the commander of the police At 8:30 p.m., the fire department spokes- provide a heavy rescue vehicle and a crane truck
department to meet on the scene and coordi- man arrives on site and consults with the inci- at 8:46 p.m. In the course of the operation,
nate the ongoing response. dent commander. the crane truck is used to lift the truck and
At 8:14 p.m., the dispatch center issues At 8:38 p.m.—36 minutes after the incident its trailer, so that the bodies can be recovered.
a pre-alert for the emergency service fast- began—the first patients in triage category 1 At 9:05 p.m., the ten more ambulances are
response unit operated by the German Red are transported to hospitals. dispatched to Breitscheidplatz at the request
Cross, a team of off-duty personnel and vol- At 8:40 p.m., a fire department spokesman of incident command.
unteers qualified to work in emergency ser- gives the first live interviews to approximately From 9:10 p.m. to 9:20 p.m., the German
vices. The dispatch center formally alerts the 100 journalists, who are eagerly waiting for Red Cross units arrive on scene. The team con-
unit four minutes later. more information on two sides behind the sists of an incident commander, the emergency
At 8:20 p.m., 10 additional ambulances
and two more emergency doctor’s vehicles are Figure 1: Map of incident scene and operations organization
requested by incident command. The alert is
initially delayed because of a software prob- Berlin Zoo
rail station Staging area
lem at the dispatch center.
At 8:23 p.m., additional emergency per-
sonnel are dispatched to care for uninjured Ambulance Berlin Zoo
witnesses, including a consultant from the staging area
non-profit organization.
Movie theater
After the attack is confirmed and with the
Incident command Medical division Patient treatment area:
number of victims rising, the dispatch center command post category 1 and 2
post
begins pre-alerting hospitals at 8:25 p.m. and
continues this until 8:50 p.m. Additionally, Waldorf Ambulance
loading zone Shopping
Astoria Hotel center
every fire station is informed about the ongo-
Budapest
ing operation via loudspeaker announcements. Kantsrasse er Strass e
Breitscheid-
Between 8:28 p.m. and 8:35 p.m., incident platz
command requests six more fire trucks and
Christmas market
two command vehicles, as well as emergency Kaiser
psychosocial care for the relatives of those Patient treatment Wilhelm Ambulance bus
area: category 3 Memorial (category 3 patient treatment)
affected, bystanders and emergency person- Church
nel who were first on scene. The psychosocial 50 m
unit treats 60 people by the end of the night.

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1806JEMS_27 27 5/14/18 7:58 AM

 VEHICLES AS WEAPONS
service fast-response unit, the care service and
four ambulances. The fast-response unit is ini-
tially dispatched to act as reserve emergency
personnel, but the team is later called on to
treat patients in the Berlin Fire Department’s
ambulance bus. The four ambulance crews
begin taking care of patients. The care service
sets up an emergency shelter for relatives and
eyewitnesses in the Waldorf Astoria Hotel.
By 9:30 p.m.—one hour and 28 minutes into
the incident—all patients of the triage category
1 and 2 have been transported to local hospi-
tals. Because many of the ambulances in Berlin
Numerous ambulances, emergency doctor’s vehicles and fire trucks line the road of Budapeter Strasse,
which runs parallel to the Christmas market. Photo courtesy Berliner Feuerwehr
28 JEMS | JUNE 2018
1806JEMS_28 28
have already been dispatched, the control cen-
ter requests five ambulances from Brandenburg,
which then gather at the Charlottenburg Nord
fire station and remain on standby.
At 9:37 p.m., the coordination service
at the dispatch center alerts the Berlin Fire
Department’s post-incident care team (called
“Einsatznachsorgeteam”). The Moabit fire
station becomes the contact point for emer-
gency personnel.
A fire department spokesman gives more
interviews about the operation around 9:55
p.m., after verifying with the numbers of
injured, persons affected and fatalities.
At 10:30 p.m., on-site incident command
contacts the control center and reports, “The
scene of incident is under control.”
All patients in triage category 3 are now
being treated in hospitals.
As emergency personnel gradually begin
to leave the scene, a loud bang is heard sud-
denly, just before the end of the operation. The
noise is soon attributed to police blowing up
an ownerless suitcase at an adjacent crosswalk.
In total, the vehicle attack left 12 people
dead and 67 injured, some of them seriously.
Most patients had blunt force injuries due to
being run over or due to direct impact with
the truck.
According to forensics, the deceased were
so severely wounded they had no chance to
survive. The patients were distributed to 22
hospitals and, by Dec. 22, 30 patients had
been discharged.
On Dec. 21, a large debriefing involving
66 emergency service employees took place.
A post-incident care team consisting of 23
employees from across Germany stayed on-site
to help with post-incident stress management
and psychological well-being.
INSIGHTS & LESSONS LEARNED
The authors spoke to Rolf Erbe,
who is in charge of MCI and spe-
cial operations training at the Ber-
lin Fire and Rescue Academy,
about the strengths and weak-
nesses of the operation as well as lessons learned.
What was your first impression of the
incident scene?
Rolf Erbe: For a long time, I thought, or rather
hoped, that it was an accident—perhaps a
truck driver fell asleep at the wheel. My col-
leagues thought so too, by the way. It was eerily
quiet at the incident scene. No one yelled at
all. The many first aiders and my colleagues
were highly focused while treating patients
on scene. The lights of the stalls were still on
and at first glance you didn’t see that the truck
had driven over the market, because he steered
exactly through the alleyway between the stalls.
What tasks where you assigned to during
the incident?
Rolf Erbe: After consultation with the coordina-
tion service, I was originally sent to the Haden-
bergstrasse to document and assist our press
service. I arrived during the early stages of the
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5/14/18 7:58 AM
 operation, about 20 minutes after the incident.
There weren’t enough emergency personnel
on scene, so I was appointed to triage for the
next 30 minutes. During initial screening of
patients, I just counted the injured to help us
get clear figures.
During the second round, we triaged the
injured using the START algorithm. Many
of them had already received treatment from
my colleagues. After triage was complete, I
documented the operation.

What did you learn from your experience

counting patients during triage?
Rolf Erbe: In my experience, the number of
patients you initially see at a large MCI is
half the actual number. I initially counted 25
injured patients in the first round of triage,
but we actually treated over 50.
I drew the conclusion that the incident
commander has to prepare for this: Always
plan for double by utilizing an additional Triaged category 1 and 2 patients receive care in a medical tent across from the incident site.
treatment area and reserve personnel, for Photo courtesy Berliner Feuerwehr
example. This is something that is also known
from different application areas and simply for police personnel and bystanders adminis- What went well?
means: Get an overview of the situation and tering first aid. 1. The ability of emergency personnel to muti-
ensure backup. The topic of safety at such operations is task proved very effective. We were con-
also a concern. I don’t believe that there will stantly assessing the scene for danger while
What else did you learn from triaging ever be complete safety. performing the necessary medical measures.
patients at this incident? As long as there are no concrete indications 2. The use of tourniquets saves lives. Only
Rolf Erbe: When there are a high number of of danger or threat, we will always do every- after the attacks in Paris did they become
patients at an MCI, the first overview has to thing we can to save human lives. a permanent fixture in our equipment.
be done as soon as possible, because it’s cru-
cial for the decisions the incident commander
makes and in planning the way the incident
will be handled.
The pre-triage system must be well-known
by personnel and must actually be used to
identify and tag the critically injured in a very
short time so that the appropriate resources
can be assembled in an enough time to save
as many human lives as possible.

What tools or knowledge are critical for

emergency services personnel in high-
risk situations?
Rolf Erbe: There has to be preplanning that’s
specific to high-threat situations, a system for
pre-triage should be in place, and there must
be training, planning and coordination with
other agencies, such as with police.
Equipment usually required for MCIs
should be supplemented with enough sup-
plies needed to treat special injury patterns
associated with high-risk MCIs or terrorist After consulting with the incident commander, a Berlin Fire Department spokesman answers questions
attacks. There should also be enough supplies from the many journalists on scene. Photo courtesy Berliner Feuerwehr

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 VEHICLES AS WEAPONS
Table 1: Emergency personnel deployed to Christmas market truck attack
Berlin Fire Department
(153 members deployed)
26 ambulances
9 fire trucks (professional)
4 emergency doctor's vechicles
2 incident commanders (level B)
2 incident commanders (level C)
2 mass casualty vehicles
1 fire truck (voluntary)
1 heavy rescue vehicle
1 crane truck
1 ambulance bus
1 command unit
1 press spokesperson
German Red Cross
(70 members deployed)
4 ambulances
2 vans with MCI equipment trailer
2 command vehicles
1 four-stretcher ambulance
1 fast-response care unit
1 crisis intervention team
1 fast-response emergency
service unit (partial team)
3. It allowed us to test our concepts, and we
concluded that the concepts are good, and
that they work.
4. It’s a reminder that although plans of action
are important, we have to act on them and
follow the plan. Deviation from the standard
operating procedure always leads to problems,
no matter how good the intentions were. Can-
cellation and alterations must not happen.
Did anything cause problems for you?
Rolf Erbe: Although the digital radio worked
properly, we were surprised to discover that
30 JEMS | JUNE 2018
1806JEMS_30 30
Reserve & Other
Emergency Personnel
(including off-duty personnel)
5 ambulances (Brandenburg EMS)
150 voluntary firefighters
21 fire trucks (voluntary)
8 ambulances (voluntary)
1 command unit (voluntary)
misc. off-duty Berlin Fire Dept.
personnel
15 members of German Red Cross
(Berlin-City)
Other Personnel
Governing Mayor of Berlin
Senator for the Interior and Sport
State Secretary for the Interior
Senator for Economics, Energy and
Enterprises
Provincial Fire Protection Director
Provincial Fire Protection Deputy
Director
Chief of Police
17 psychosocial emergency care
personnel
follow-up care team
some of the radio devices dialed into one par-
ticular radio installation again and again. This
led to communication problems. The commu-
nication with the control center and with other
authorities always had to be verified.
The internal communication at incident
scenes is very important but often gets neglected.
After an alleged terrorist attack, all emergency
personnel want to know, “Am I safe?”
What did you notice about the psychologi-
cal support and aftercare of personnel?
Rolf Erbe: Care for affected personnel by
the psychosocial emergency care (PSNV )
went very well. However, we have to improve
the care for the relatives and the many first
aiders who fell through the cracks.
How did the many deployed emergency
crews feel?
Rolf Erbe: Many of my colleagues were ask-
ing themselves if they did everything they
could possibly do. Forensics gave us the
feedback that no patient died because of
insufficient treatment or a delayed trans-
port. That was very helpful knowledge in
this situation.
What will change in Berlin as a result of
this incident?
Rolf Erbe: We’re reviewing the events at all
levels, and we will improve in as many areas
as possible. For example: We realized that we
didn’t bring any materials for bystanders to
provide first aid while on scene. Resources were
very limited, especially at the beginning. The
fire and police departments both get money
for equipment and advanced training from
the safety package provided by the regional
government of Berlin.
We hope to purchase backpacks for our
vehicles and for police vehicles that each
contain slings and a supply kit for surgi-
cal injuries. We also think that this will
strengthen cooperation and joint training
with other authorities.
What impressed you most?
Rolf Erbe: Many of my colleagues from the
professional fire service, the volunteer fire ser-
vice and administrative personnel who were
off-duty reported to their fire stations with-
out being asked in order to provide help and
assistance. This support is very important for
us. Praise from politicians and the public also
helps emergency personnel with their process-
ing of the operation. JEMS
Johannes Kohlen, EMT-P, is a paramedic
and journalist. He has a Bachelor of Arts
in journalism and media management.
He’s also a trauma management instruc-
tor in the German trauma network.
Klaus Runggaldier, PhD, EMT-P, is a
paramedic and managing director of Falck
in Hamburg, Germany. He’s also dean and
professor at Medical School Hamburg in
the University of Applied Sciences and
Medical University.
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5/14/18 7:58 AM
 BERLIN, GERMANY
Berlin is the capital of Germany. Its 9,601.4 square
feet (893 square meters) are home to approxi-
mately 3.53 million people. A hub of commerce
and tourism, the city has many international visi-
tors who explore the city alongside citizens using
various routes winding through the metropoli-
tan area, including 205.05 miles (330 kilometers)
of railway tracks, 186.41 miles (300 kilometers)
of streetcar rails, 90.72 miles (146 kilometers) of
subway tracks and 47.85 miles (77 kilometers) of
highways. The city has a large, centrally located
airport, 31 hazardous incident plants, as well as
multiple ministries and embassies that pose spe-
cial challenges for emergency services personnel.
BERLIN FIRE DEPARTMENT
Founded in 1851, the Berlin Fire Department,
referred to in Germany as “Berlin Feuerwehr,” is
the oldest professional fire department in Ger-
many. With 3,200 profes-
sional firefighters, it’s the
country’s largest fire depart-
ment. Personnel work out
of 34 fire stations and the department staffs for
553 operational functions, not including the dis-
patch center, service units and other back-office
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1806JEMS_31 31
services. Every station has at least one fire truck
and two ambulances available at all times. In
addition, there are 58 voluntary fire departments
with a total of approximately 1,400 members—
an important resource contributing to the effec-
tiveness of the Berlin Fire Department and are
used as a fixed component when operations are
planned. The city also has a youth fire department
that’s made up of approximately 1,000 members,
of which over 200 are female.
EMS IN BERLIN
In Germany, EMS is referred to as “rettungsdienst”
(which in English, literally translates to “rescue ser-
vice”). ALS care is typically rendered by a specially
trained emergency physician called a “notarzt”
(i.e., emergency doctor), who arrives on scene in a
non-transport vehicle and meets up with mobile
ICUs and BLS ambulances on high-acuity scenes,
or at incidents that have the possibility of pre-
senting high-acuity patients.
In 2016, Berlin firefighters
were dispatched to handle
454,143 calls, of which 374,942
were for EMS—up from 363,599 in 2015, as well
as 333,199 in 2014. Due to the large increase
in the number of calls each year, the Berlin Fire
Department has increased its resources. Since
April 10, 2017, 139 emergency vehicles and 24
emergency doctor’s vehicles report for duty on a
daily basis to handle EMS calls, an increase of 20
ambulances and four emergency doctor’s vehi-
cles from 2016.
Additionally, an EMS helicopter, Christoph 31,
is dispatched for approximately 2,500 calls annu-
ally. An intensive care transport helicopter based
at the Berlin Emergency Hospital is dispatched
about twice daily. The Berlin Fire Department also
has two specially equipped stroke vehicles, which
include a mobile CT scanner, the latest laboratory
technology and telemedicine capabilities.
There are 38 hospitals in Berlin. Of those, six are
national hospitals and 17 are regional trauma cen-
ters. Basic care is provided by 15 clinics.
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1806JEMS_32 32 5/14/18 8:04 AM

 Unmanned aerial vehicles
for EMS & rescue applications
By Andreas Claesson, RN, EMT-P, PhD
O
ut-of-hospital cardiac arrest (OHCA) affects
nearly 360,000 individuals in the United States
and about 300,000 in Europe each year. Survival
rates are low.1,2
In Sweden, 5,312 OHCA cases were reported to the
Swedish register for cardio-pulmonary resuscitation
(SRCR) during 2016.3 CPR was initiated either spon-
taneously by bystanders, guided from the dispatch center
through telephone CPR or on arrival of EMS, which took
place after a median of 13 minutes from cardiac arrest.3
Overall 30-day survival was 11% (n = 577) and a major-
ity of these (93%) had a favorable neurological outcome,
with a cerebral performance category (CPC) score of 1–2.3
Time to treatment with a defibrillator is the single most
important factor for survival, and each minute without CPR
treatment decreases the chance of survival by
10%.4,5 Early use of a defibrillator within
the first five minutes has a poten-
tial to save up to 50–70% of
all patients suffering from
an OHCA.6,7
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1806JEMS_33 33
Early CPR performed by bystanders, dual dispatch
using firefighters and public access defibrillation programs
(PADs) have been introduced in Stockholm County and
have been shown to reduce time to defibrillation.6
These interventions have proven successful in both
urban areas and in public locations, but despite EMS
response time improving in rural areas of Stockholm
County with dual-dispatch intervention, it had little or
no effect on survival.8
A lot of effort is put in to PAD projects around the world,
and there are a variety of systems for alerting bystanders
of nearby AEDs, or other ways of dispatching AEDs to
OHCA victims. However, AED usage in OHCA is still
low in relation to the proportion of available AEDs.7
A novel way of decreasing the delay in remote areas
with long EMS response times from collapse to first shock,
may be to use an unmanned aerial vehicle (UAV—more
commonly referred to as a “drone”) to quickly deliver an
AED to bystanders.
Drones have been predicted to be increasingly used
by EMS for delivery of medical products,9,10 however,
regulations on limitations in wind, flight endurance and
payload need to be developed in order to ensure drones
are utilized safely.
Drone systems have a strong potential to facilitate lifesaving
medical interventions, such as transporting and delivering an AED.
Photos courtesy Andreas Claesson
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5/14/18 8:04 AM
 LIFESAVING DRONES
STUDY DESIGN
In 2013, the Centre for Resuscitation Science
at the Karolinska Institute in Sweden initiated
a drone project, with the intent to reach victims
of cardiac arrest in rural areas at an earlier stage.
Drone technology was evolving, and a
methodology for facilitating early defibril-
lation with such a system had not yet been
described in the literature. Neither EMS and
first responders, nor volunteers via smart-
phones, could reach the victims in time.
A geographical information system (GIS)
was used to predict optimal locations for
drones equipped with AEDs in Stockholm
County. In this deployment strategy, a total of
3,165 OHCAs occurring between 2006–2013
were analyzed by weighing OHCA incidence
per 100,000 inhabitants and EMS response
time.12
The GIS model predicted 20 optimal loca-
tions of drone placement (10 in urban areas and
10 in rural areas). The time savings in urban
areas was estimated to 1.5 minutes, with the
drone arriving before EMS in 32% of cases.
However, in 124 cases of rural OHCA, the
drone was calculated to arrive before EMS
in 93% of cases, with a mean time savings of
19 minutes.12
The coastline and archipelago surround-
ing the city of Stockholm is heavily inhabited
during summertime, with no additional EMS
resources. EMS response time is prolonged
in the area, especially on the islands where
publicly accessible AEDs are rare. Similar
GIS findings have been made in Canada and
the U.S., supporting the benefits of providing
such a model.13,14
Different AED delivery methods were
tested, including landing the drone, para-
chute-release, and using a latch-release from
a low altitude.
The latter two methods, however, intro-
duced risks of imprecision and of damaging the
An AED-equipped drone can be deployed from
dispatch within just three seconds and followed
predefined flight corridors that would minimize
disruption and risk to the community.
34 JEMS | JUNE 2018
1806JEMS_34 34
defibrillator after dropping it onto the ground.
Following the explorative GIS data and
the testing of AED deployment, researchers
submitted applications to the transportation
board to operate test flights where the drone
could be seen within a pilot’s range of sight.
These flights were planned over nine months,
and the team focused on mapping the geo-
graphical area, predefining flight corridors so
the drone flew above uninhabited areas, set-
ting up routines and informing local author-
ities, EMS and members of the community.
Redundant communication systems and a
high-quality video link within the 3G/4G net-
work was used to remotely monitor and pilot
the aircraft. With a daily notice to airmen, dis-
patch and flights based on historical OHCAs
were performed in October 2016, with the
results published in JAMA in June 2017.15
A local dispatch center was set up at a fire
station within the proposed testing area in
Norrtälje County, and direct communication
with air traffic control was maintained during
these short flights, which were operated at a
median of five minutes at low altitude (100
meters) at a maximum distance of 9 kilometers.
Data showed that the drone could be
deployed from dispatch within just three
seconds, with a total median time savings of
16 minutes from dispatch to arrival onsite
vs. EMS.15
The short delay for dispatch didn’t take into
account time for uncovering the drone from
its housing, an important factor to take into
account when considering future integration
into control structures.
All test flights followed predefined routes
that ensured residential areas were geo-fenced,
in order to minimize risks and disturbances
in the community. Additional risk mitigation
tactics included the use of redundant commu-
nication systems, return-to-home features and
emergency controlled landing.
After the drone has arrived on scenedeliver its AED,
an EMS vehicle transports it back to its station.
Even though straight flight lines seem intu-
itive, there are advantages in defining altitudes
and flight corridors in order to minimize inter-
ference with other aircraft. Additionally, the
use of radar or airborne collision avoidance
systems are also advised. In order to arrive
within 3–5 minutes after a cardiac arrest, early
recognition at the dispatch center is crucial,
followed by early dispatch of the drone and
prompt flight times.
Although a battery-powered drone was
used during the study, the size of the vehi-
cle and the fuel used raised some questions.
From the victim’s perspective, it doesn’t matter
whether the drone weighs five or 100 kilo-
grams. They don’t care where the drone gets its
power to fuel operation (e.g., battery, hydro-
gen or jet fuel), as long as the response time is
short and the AED is presented to a bystander
in an intuitive way that minimizes the time
to defibrillation.
In Stockholm, trained civilian “SMS lifesav-
ers” have been strategically positioned through-
out the service areas and dispatched using a
smartphone app since 2015.16 These volunteers
have the potential to be co-alerted to pick up
an AED delivered by a drone, especially if the
landing site is > 100 meters from the location.
Experience shows that there’s risk involved
in landing the drone in a public space. The
drone’s lights, siren and engine noise tends
to attract attention, and its still-rotating pro-
pellers can present a danger.
It’s believed that by using a winch in the
future to lower the AED may promote safer
delivery to bystanders, EMS or other first
responders who are on site.
Communications with the drone may also
improve when the drone is elevated, instead
of hidden behind obstacles such as houses or
hills. This will also conserve battery power/
fuel so that the drone can still return to base
if landing isn’t feasible.
Important questions have been raised
regarding the feasibility of implementation
at the community level and there may be
many challenges.17
Although regulations differ in various coun-
tries, aviation legislation is similar across all
high-income countries, with regulations focus-
ing on safety for people on the ground as well
as those in manned aircraft.
Drone technology is already at a level to
facilitate early defibrillation in OHCA. How-
ever, there are several considerations and ques-
tions that must be asked in order to take a
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5/14/18 8:04 AM
 structured approach to evaluating all the links
in the chain of drone deployment.
If not planned properly, integration of drones
at the dispatch center could delay traditional
EMS response or dispatcher-assisted CPR.
In addition, arrival of the drone on scene
may cause prolonged hands-off intervals, as
the bystander waits for the drone vs. perform-
ing high-quality CPR.
Designing an AED drone system for use
in real-life OHCA cases is complex, requiring
interaction of technology, regulations, bystand-
ers and EMS control structures. Each area or
region considering drone delivery of AEDs
will need thorough testing in order to facilitate
safe arrival of the drone and actual use of the
AED during the first minutes of an OHCA.
DRONES FOR DROWNING
At the same time our researchers were study-
ing drone delivery of AEDs on land, AED-
equipped drones were also deployed for several
historical drowning incidents of OHCA that
occurred at Tylösand public beach, where the
victims were discovered too late in the drown-
ing process.
Tylösand is visited by nearly 50,000 bath-
ers on a sunny summer day, with strong rip
currents present in high wind conditions.
Off-the-shelf drones (specifically, the DJI
Phantom 4) were tested in simulated settings
to determine whether the drones could suc-
cessfully send live video from an altitude of
60 meters down to rescuers using a tablet
to watch the video and quickly locate sub-
merged victims.18
The first drones for search and rescue pur-
poses in Scandinavia were implemented in
June 2017 at Tylösand surf-lifesaving club.
In addition to providing situational aware-
ness and facilitating early positioning of
submerged individuals, there are future pos-
sibilities of providing early flotation to drown-
ing victims by dropping self-inflatable buoys.
The drones may also see future use for ice
rescue, with the drones delivering buoyancy
and lines to victims trapped in breaking ice.
Testing this concept is already underway in
the Göteborg area.
CONCLUSION
Drone systems have a strong potential to facil-
itate lifesaving medical interventions, such as
transporting and delivering an AED in cases
of OHCA. Our three-year vision is to imple-
ment a drone system that will autonomously
www.jems.com
1806JEMS_35 35
Regulations regarding flight conditions, endurance and payload need to be developed in order to ensure
drones are utilized safely.
dispatch to OHCA patients in suitable areas,
defined by current regulations in the jurisdic-
tion, controlled airspace considerations, and
other factors associated with air traffic security.
We would like to encourage fire depart-
ments and EMS systems worldwide to learn
more about the potential of deploying drone
technology for both OHCA and water life-
saving purposes. JEMS
Andreas Claesson, RN, EMT-P, PhD, is a
registered nurse and paramedic in Western
Sweden. He also holds a post-doctorate
research position at the Centre for Resusci-
tation Science at the Karolinska Institute in
Stockholm, where he focuses on innovative methods for early
defibrillation for patients in cardiac arrest. This includes
SMS-lifesaving dispatching of laymen and the use of unmanned
aerial vehicles (i.e., drones) for delivery of AEDs in rural or
hard-to-serve areas. He’s the chair of the Swedish resuscita-
tion council, a position he’s held since 2017. He can be reached
at andreas.claesson@ki.se.
REFERENCES
1. Mozaffarian D, Benjamin EJ, Go AS, et al. Executive sum-
mary: Heart disease and stroke statistics—2016 update:
A report from the American Heart Association. Circulation.
2016;133(4):447–454.
2. Atwood C, Eisenberg MS, Herlitz J, et al. Incidence of EMS-
treated out-of-hospital cardiac arrest in Europe. Resuscitation.
2005;67(1):75–80.
3. Swedish CPR Council. (2017.) Annual report 2017. Retrieved
Dec. 7, 2017, from www.hlr.nu/hjart-lungraddningsregistret/.
4. Valenzuela TD, Roe DJ, Cretin S, et al. Estimating effectiveness of
cardiac arrest interventions: a logistic regression survival model.
Circulation. 1997;96(10):3308–3313.
5. Waalewijn RA, de Vos R, Tijssen JG, et al. Survival models for
out-of-hospital cardiopulmonary resuscitation from the perspec-
tives of the bystander, the first responder, and the paramedic.
Resuscitation. 2001;51(2):113–122.
6. Valenzuela TD, Roe DJ, Nichol G, et al. Outcomes of rapid defibril-
lation by security officers after cardiac arrest in casinos. N Engl
J Med. 2000;343(17):1206–1209.
7. Ringh M, Jonsson M, Nordberg P, et al. Survival after public
access eefibrillation in Stockholm, Sweden: A striking success.
Resuscitation. 2015;91:1–7.
8. Nordberg P, Jonsson M, Forsberg S, et al. The survival benefit of
dual dispatch of EMS and fire-fighters in out-of-hospital car-
diac arrest may differ depending on population density—A
prospective cohort study. Resuscitation. 2015 May;90:143–149.
9. Floreano D, Wood RJ. Science, technology and the future of small
autonomous drones. Nature. 2015;521(7553):460–466.
10. Thiels CA, Aho JM, Zietlow SP, et al. Use of unmanned
aerial vehicles for medical product transport. Air Med J.
2015;34(2):104–108.
11. Abrahamsen HB. A remotely piloted aircraft system in major
incident management: Concept and pilot, feasibility study. BMC
Emerg Med. 2015;15:12.
12. Claesson A, Fredman D, Svensson L, et al. Unmanned aerial vehi-
cles (drones) in out-of-hospital-cardiac-arrest. Scand J Trauma
Resusc Emerg Med. 2016;24(1):124.
13. Boutilier JJ, Brooks SC, Janmohamed A, et al. Optimizing a drone
network to deliver automated external defibrillators. Circulation.
2017;135(25):2454–2465.
14. Pulver A, Wei R, Mann C. Locating AED enabled medical drones
to enhance cardiac arrest response times. Prehosp Emerg Care.
2016;20(3):378–389.
15. Claesson A, Bäckman A, Ringh M, et al. Time to delivery of an
automated external defibrillator using a drone for simulated
out-of-hospital cardiac arrests vs emergency medical services.
JAMA. 2017;317(22):2332–2334.
16. Ringh M, Rosenqvist M, Hollenberg J, et al. Mobile-phone dis-
patch of laypersons for CPR in out-of-hospital cardiac arrest. N
Engl J Med. 2015;372(24):2316–2325.
17. Mark DB, Hansen SM, Starks ML, et al. Drone-based automatic
external defibrillators for sudden death? Do we need more cour-
age or more serenity? Circulation. 2017;135(25):2466–2469.
18. Claesson A, Svensson L, Nordberg P, et al. Drones may be used
to save lives in out of hospital cardiac arrest due to drowning.
Resuscitation. 2017;114:152–156.
jUNe 2018 | JEMS 35
5/14/18 8:04 AM

Israel’s Magen David Adom provides nation-
wide EMS response
By Eli Jaffe, PhD, EMT-P; Rafael Strugo, MD & Oren Wacht, PhD, EMT-P
I
srael’s EMS and blood services are based
on a national organization, Magen David
Adom (MDA), which is also known as
Israeli Red Cross Society. MDA serves the
entire population of Israel both during peace-
times as well as during conflicts and wars.
MDA is a non-governmental,
AL
N AT I O N
non-profit organization, established
before the state of Israel, and works
under direction of the 1950 MDA
ER
Law as passed by the Israeli Parlia-
ment. The organization is a voluntary
one in its core, whereby the volunteers not
only take part in the operative activities, but
they’re also an inseparable part of its manage-
ment—the National Council and the Man-
agement Council.
36 JEMS | JUNE 2018
1806JEMS_36 36
Nearly all of MDA’s management started
their path in MDA as volunteers, and the same
is true for most of the employees who staff
the ambulances and Mobile ICUs (MICUs).
MDA operates several arms to provide
EMS response on a national level, includ-
JEM ing a dispatch center, Life Guardians,
first responders, BLS ambulances,
S
intensive care ambulances and heli-
ARTIC
copter EMS. There are currently
LE
I NT 162 ambulance stations across Israel,
where some 22,000 volunteers (approx-
imately half are youth volunteers) and
2,180 paid employees are active. Although
the employees provide the basis of the EMS
service, the volunteers are a critical part of
the service.
Approximately 500 volunteers respond using dedi-
cated motorcycles outfitted with first aid supplies,
AEDs and other lifesaving equipment.
Photos courtesy Magen David Atom
DISPATCH CENTER
In Israel, the phone numbers for each of the
emergency services are different. The phone
number for MDA is 101. All dispatch center
employees, both call takers and dispatchers, are
either EMTs or paramedics, and have some
experience in the field.
Dispatch center technology is developed
in house, and offers some of the leading tech-
nology in dispatch centers today. The Control
and Command program allows dispatchers to
locate the caller via GPS, transmit information
such as previous conditions of the patient, live
pictures and video from the scene and even a
chat option in as many languages as are cov-
ered by Google’s translation services.
The dispatcher can also see the location of
any nearby police and fire vehicles, as well as
use the social app Waze to locate an accident
or any traffic problems.
To reduce abandoned calls, the average time
taken to answer a call in the dispatch center
stands at only three seconds. The speed of this
www.JEms.com
5/14/18 8:05 AM
 All dispatch center employees are either EMTs or
paramedics, and have some experience in the field.
response is largely made possible by advanced
telecommunication systems that locate the first
available call taker in any of Israel’s 10 dispatch
centers regardless of the caller’s location.
A unique aspect of MDA’s dispatch is that
all the centers work on the same system, there-
fore if someone calls and gets through to a
different region, the call taker can still assist
and receive the caller’s information.
For example: A caller in Tel Aviv who
calls MDA may actually be answered by a
dispatcher in Jerusalem, because the time to
answer the call in Jerusalem at that moment
is shorter. The call is handled in the Tel Aviv
dispatch center by the chief of the shift, exactly
like it was taken in Tel Aviv, since all the info
is in the same system. Any dispatcher in Israel
in any dispatch center can see all ambulances,
manpower and available resources through-
out Israel. The advantages of a national,
custom-made system are significant. If a dis-
patch center goes offline—for any reason—all
the calls and all the ambulances can still be
www.jems.com
1806JEMS_37 37
dispatched from a different dispatch center.
The MyMDA app is available free to any-
one in Israel. It’s a fast and efficient way to
dispatch MDA crew, and the app stores all
the patient’s details, along with those of the
patient’s immediate family. Details such as pre-
vious medical history, ECGs, medication and
allergies can be entered by the patient along
with the patient’s own details and their fam-
ily members’ details.
Dialing via the app allows for GPS loca-
tion of the call to appear in the Command
and Control program, as well as the patient’s
medical file. It also allows a chat option in
any language, and facilitates communication
with deaf or mute callers. Using the app cuts
a considerable amount of time off the call, and
allows for faster dispatch of crews. Any call a
crew is dispatched to has all the past medical
info of the patient available immediately on
the tablet in the ambulance or on the crew
members mobile phone, allowing them to save
valuable time when treating a patient.
LIFE GUARDIANS &
FIRST RESPONDERS
Rapid arrival at the scene of medical emergen-
cies is further made possible thanks to the tens
of thousands of Life Guardians and volunteers
who are spread across the country, and who
are located via the Command and Control
program and dispatched via a dedicated app.
Life Guardians are doctors, nurses, para-
medics, EMTs and many others in Israel who
have the knowledge and skill to perform CPR
as well as treat choking, bleeding and other
medical emergencies. Located throughout the
country, Magen David Adom’s dispatch center
can activate them by using cellphone location
services. Tens of thousands have downloaded a
dedicated app to their cell phones that enables
MDA to utilize them if they’re within two
minutes of a medical emergency. Despite the
fact that these aren’t necessarily MDA vol-
unteers, Life Guardians are still willing to
be called upon to assist in emergencies, and
answers dozens of calls each month.
jUNe 2018 | JEMS 37
5/14/18 8:05 AM
 VOLUNTEERING TO SAVE LIVES

MDA has developed an approach that combines

“scoop and run” and “stay and play,” to provide the
minimal lifesaving treatment without wasting time,
especially in trauma.

Dispatching First Responders to emergency rapidly searches for the nearest First Respond- Responders means that in both urban and rural
calls is a practice that’s done throughout the ers and sends them a message. The volunteers areas of Israel, the average arrival time at any
world, and is usually handled by emergency use the app to confirm whether they’re avail- emergency call is less than five minutes.
teams such as fire departments or the police. able to respond or not as well as their arrival on
MDA uses a different approach: volun- scene. They can even use the app to complete GROUND RESPONSE & TRANSPORT
teer EMTs. A national unit of 8,000 MDA has around 1,000 ambulances
active volunteer First Responders in ambulance stations across the coun-
are dispatched via a dedicated app
and a special dispatch center. These In both urban & rural areas try. Over half of these are in active ser-
vice, while the rest are for use during
volunteers, which include teachers,
lawyers, freelancers and others, are of Israel, the average arrival emergency times or war times—ready
to be activated on a moment’s notice.
active volunteers on the ambulances
at MDA stations. time at any emergency call The Life Support ambulances are
spread across the 147 MDA stations
First Responders carry emergency
medical equipment that’s identical is less than five minutes. nationwide, and are also operated
in rural areas by volunteer respond-
to what’s carried in an ambulance. ers. The basic treatments provided
Some 500 First Responders use a by the crews on these ambulances
Medi-Cycle, which is a dedicated motorcy- the relevant forms documenting any treatment include CPR, automatic defibrillation, EpiPen
cle with first aid equipment, AEDs and other provided. First responders not only arrive first administration, aspirin administration, basic
lifesaving equipment. The rest of the First on scene to provide crucial medical treatment, first aid, fluid resuscitation, childbirth and hos-
Responders travel in their own private vehicles. but they also provide critical help to the ambu- pital transport. Each ambulance is staffed by
When a call is received and entered into the lance teams when they arrive. a crew made up of an EMT driver alongside
Command and Control program, the system The use of Life Guardians and First either adult or youth volunteers. The adult

38 JEMS | JUNE 2018 www.JEms.com

1806JEMS_38 38 5/14/18 8:05 AM

 volunteers are all trained to the level of EMT kilometers from major hospitals. is a part of Israel’s national health insurance.
or advanced EMT. The youth volunteers, aged For this purpose, MDA operates two inten- The Israeli defense forces also operate mili-
15–18, qualify as First Aiders, having under- sive care helicopters that have been in service tary helicopter EMS which can be called to
gone a 60-hour training course. since 2007. Each helicopter is manned by two enhance the civilian EMS.
There are 379 MICUs or ALS Ambulances flight paramedics who have undergone special-
that are dispatched to emergency medical inci- ized training, and are each able to transport ROUTINE EMERGENCY RESPONSE
dents that require advanced treatment. These two patients simultaneously. By law, MDA is designated as Israel’s Red Cross
units are operated from MDA stations and The main purpose of the helicopters is to organization, and acts a medical auxiliary during
are staffed by paramedics alongside EMT and transfer patients to specialized medical centers states of emergency. The country experiences a
advanced EMT drivers. when appropriate. This means that the helicop- high number of war and terror acts which are
MDA has developed an approach that com- ter is usually dispatched after the arrival of the regularly carried out against the civilian pop-
bines “scoop and run” and “stay and play,” to pro- first crew at the scene. In cases where there’s a ulation. MDA provides the immediate medi-
vide the minimal lifesaving treatment without substantiated assumption that the helicopter cal care given to the population during states
wasting time, especially in trauma. Calls are will be required, or if the Command and Con- of emergency and war times.
categorized according to the severity and type trol center has received pictures or video from Therefore, MDA crews have a great deal of
of the problem, which means certain calls are the scene, the helicopter will be dispatched even experience in dealing with mass casualty inci-
treated as Type A (i.e., scoop and run), while before the arrival of the first crew. dents (MCIs) as a result of terrorism. In the
other calls will be treated as Type B (i.e., stay The funding for helicopter EMS operations last 20 years, there have been approximately
and play). A gunshot victim with an abdominal
injury, for example, will be a Type A, whereas
a patient in acute congestive heart failure will
be treated as a Type B.
The paramedic’s authority lies within Health
Ministry regulations and allow for paramedics
to perform advanced airway treatment by intu-
bation, emergency tracheotomy, needle decom-
pression of the chest, defibrillation, external
pacing, administration of IV and intraosseous
drugs and many more.
The MDA paramedic can also pronounce
death. For purposes of supervision and control,
as well as to aid the paramedic in the field, there’s
a National Medical Center that’s manned by
a board-certified physician and a senior para-
medic. They can view the monitor, ECG and
vital signs of the patient, speak to the crew on
a recorded line, or even by video, in an effort to
assist in the clinical decision-making process.
The MICU crew can transfer patients with
ST-elevation myocardial infarction or cerebro-
vascular accident directly to the relevant depart-
ments, bypassing the ED. The crew can even
send the patient’s data (e.g., their ECG) via a
mobile app to a senior physician phone in the
cardiology department, where the decision can
be made quickly to take the patient directly for
percutaneous transluminal coronary angioplasty.

HELICOPTER EMS
Measuring just 500 km (approximately 290
miles) from north to south, and 100 km
(approximately 85 miles) from east to west,
Israel is a relatively small country. Nevertheless,
the hospitals are in the major cities, and there
are large rural areas, particularly in the north Mobile ICU crews can transfer patients with ST-elevation myocardial infarction or cerebrovascular accident
and south, that are sometimes a few hundred directly to the relevant hospital departments, bypassing the ED.

www.jems.com jUNe 2018 | JEMS 39

1806JEMS_39 39 5/14/18 8:05 AM

 VOLUNTEERING TO SAVE LIVES
MDA operates two intensive care helicopters manned by two specially trained flight paramedics.
100 terrorism-related MCIs caused by both
explosions by suicide bombings and in close-
range shootings. During these incidents, MDA
utilizes and amasses a considerable response,
Magen David Adom (MDA) Timeline
1930 — MDA is established by 7 volunteers in
Tel Aviv as a treatment and transport service
for workplace injuries.
1936 — MDA’s Blood Bank is established along
with a volunteer blood donor organization.
1949 — MDA becomes a national organization
by law after Israel signs the Geneva Convention.
1950 — The “Magen David Adom Law” comes
into effect, officially recognizing MDA as Israel’s
National Rescue service. The blood services are
also recognized in law.
1972 — Shachal Service begins providing
designated ambulances for cardiac intensive
care purposes in Jerusalem.
1979 — In cooperation with hospitals and
the Israel Defense Forces, MDA establishes the
School of Paramedics and opens the first para-
medic course.
1991 — MDA moves to regional dispatch cen-
ters using advanced technologies.
1994 — MDA’s youth organization is estab-
lished. Also, the first MICU ambulance staffed
only by a paramedic (i.e., without a doctor on
board) is activated.
40 JEMS | JUNE 2018
1806JEMS_40 40
enabling the teams at the scene—including
First Responders as well as ambulances—to
evacuate all priority patients within 20 minutes
of the first call received at the dispatch center.
2000 — The First Responder unit is estab-
lished with the aim of reducing response times
and saving more lives.
2003 — Ambulance Medi-Cycles are run by
volunteers as part of first response, lifesav-
ing activities.
2006 — MDA is accepted as a full member
of the International Red Cross after a 60-year
battle for international recognition of the Red
Star of David symbol.
2007 — The National Command and Con-
trol Center, also known as the National Com-
bined Dispatch Center, is established to act
as a backup to the regional dispatch centers.
Flight medical response is also established with
one helicopter to serve the north and another
one in the south.
2008 — The American Heart Association
grants authorization to MDA’s training depart-
ment to train and issue certificates in its name.
2016 — The Life Guardians unit is estab-
lished, whereby medically qualified profes-
sionals reach emergency incidents nearby
their location.
Other terrorist incidents, including those
without a high number of casualties, occur rel-
atively frequently and require the organization
to be on a high level of alert and preparedness.
These incidents include stabbings, shootings,
vehicle rammings and others.
The organization ensures the safety of the
crews who respond to terrorism incidents and
provides them with personal protective equip-
ment. Many times, terrorists are intentionally
attempting to attack and injure the medical
crews and there is often a second explosion
that occurs following a first explosion that’s
intended to injure MDA personnel.
War acts against the civilian population come
mainly in the form missile attacks. Since the
Gulf War of 1991 until today, tens of thousands
of missiles have landed in Israeli towns and cit-
ies, and there have been thousands of injuries.
Despite this, MDA crews—both volunteers and
employees—act despite life-threatening dan-
ger, racing to reach the victims, treating them
and transporting them to hospital.
MDA’s preparedness for states of emergency
is based largely on volunteers. There are many
courses dedicated to train them for their roles,
and there’s a support system in place for those
who need it. This is especially important for vol-
unteers, and particularly after difficult incidents.
OVERSEAS ACTIVITY
Magen David Adom is sends emergency med-
ical personnel as well as vital equipment to
many disaster scenes around the world, in
cooperation with the local Red Cross organi-
zation. MDA delegations are often among the
first to reach disaster areas. This was the case
during the Southeast Asia tsunami in 2004,
and the earthquakes that hit Haiti in 2010
and and Nepal in 2015, among many others.
Along with the aid to the population, MDA
crews also assist Israelis injured in overseas
terror attacks such as in Bulgaria in 2012. JEMS
Eli Jaffe, PhD, EMT-P, is the director of training, PR, volun-
teer activities, marketing and international relations division,
of the Israeli national EMS organization Magen David Adom.
Rafael Strugo, MD, is the medical director and head of the
medical division for Magen David Adom, the Israeli national
EMS organization.
Oren Wacht, EMT-P, PhD, is the head of the bachelor degree
for paramedics at Ben Gurion University’s department of
Emergency Medicine and advisor to the Israeli ministry of
health. He’s a member of the JEMS editorial board and is also
a paramedic with Magen David Adom, the Israeli national
EMS organization.
www.JEms.com
5/14/18 8:05 AM
 R

For more information, visit JEMS.com/rs and enter 10.

1806JEMS_41 41 5/14/18 8:05 AM


Bicycle response team rolls out on
Australia’s Gold Coast
By Queensland Ambulance Service Media Unit
I
n Queensland, Australia, the smooth sound
of nobbled tires rolling along the Gold
Coast’s pathways belies the urgency of the
situation critical care paramedic Ricky Arnold
and advanced care paramedic Warren
Herlt are about to face.
It’s 11:01 a.m. on a Monday, and the
pair has just been dispatched from the
tourist strip’s iconic Cavil Mall.
Utilizing the bikeway along the Espla-
nade and Northcliffe Terrace, within three
minutes the pair reaches Northcliffe Surf
Club where a man has been pulled from
the surf.
Fortunately, the male patient is conscious
but has swallowed water, so he’s assessed and
eventually transported to Gold Coast Univer-
sity Hospital in an ambulance.
42 JEMS | JUNE 2018
1806JEMS_42 42
BOLSTERING RESPONSE
What’s different about this incident is that it’s
the first for Queensland Ambulance Service’s
(QAS) new Bicycle Response Team (BRT).
'I love riding my bike—
when I get to do it at
work it’s even better.'
The BRT was formed to bolster the QAS
response to Gold Coast 2018 (GC2018) Com-
monwealth Games.
The bicycles allow paramedics to reach
patients without having to negotiate traffic
JEM
AL
N AT I O N
S
ARTIC
ER
LE
I NT
The Queensland Ambulance Service Bike Response
Team turns heads as they ride along the bike
pathways and alleyways of Australia’s Gold Coast.
Photos courtesy Queensland Ambulance Service
snarls, closed roads or pedestrian-only areas.
In particular, Festival Zones in place during
GC2018 were expected to draw large crowds,
and the BRT added to the suite of response
options available.
Launched in November 2017, the
team works seven days a week between
10 a.m. and 8 p.m. The BRT cover an
area from Southport down to Mermaid
Beach. Personnel ride Merida Big7 hard-
tail mountain bikes with safety markings,
lighting and a primary response kit that
includes an automatic external defibril-
lator (AED), advanced airway kit and
major/minor trauma kit.
First, though, the members of the BRT
were put through a practical two-day training
course with the Queensland Police Service’s
Bike Squad, where they learned bike handling
skills and maintenance.
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 For former elite cyclist and Coral Gardens
advanced care paramedic Jane McDonald, the
BRT was an opportunity too good to pass up.
“It just seemed like a job that was made for
me—to be able to combine riding while at work,
and be involved in a program in its infancy, that’s
really nice,” McDonald said. “I love riding my
bike—when I get to do it at work it’s even better.”
The team tested its large-event capabilities
during Schoolies (2–3 weeklong high school
graduation parties) where members honed their
local knowledge.
“Our hotel knowledge since Schoolies has
lifted and continually improves every day,
McDonald said. “We’re all getting really good
at knowing where we’re going.”
“We now know the arcades,” McDonald adds. The team’s training was rigorous and expertly conducted by experienced members of the Queensland
“We know where we need to get to and we can Police Service’s Bike Squad.
utilize those arcades, smaller side streets and the
malls as well.”
Averaging around six to seven cases a day,
varying from near drownings, patients with chest
pain, collapsed patients and cut feet, the team
ride anywhere from 20 to 60 kilometers (12.5–
37.3 miles) in a shift.
“We’re riding hard, we’re really putting in,
and it adds a bit of excitement too,” McDon-
ald continues.
“It’s a really motivated, enthusiastic crew that
we’ve got,” McDonald says of her team. “Every-
one is really keen to make it work.”
The team operates from a customized unit
based at the Surfers Paradise beachfront. They
can then be deployed to other areas as needed.
The visible presence of the team has been
well-received by the general public.
“We get stopped for photos a lot.” McDon- BRT member Tara Hardy shows Commonwealth Games Assistant Commissioner Gerard Lawler what’s inside
ald says. “It’s really common for us to get flagged the team’s medical kits.
down [for photos],” Jane says. “People come up
to us and want to talk about the bikes and want
to have a chat to us.”

A SECOND TEAM
The trial of the BRT unit proved successful
enough for the concept to be expanded to Bris-
bane. The Brisbane BRT has rolled into action
and is tasked with responding to incidents in the
CBD, Fortitude Valley, Spring Hill and South
Brisbane, whether they be in parklands, shopping
precincts or private residences. JEMS

Acknowledgement: The original version of this story was

written by the Queensland Ambulance Service media unit
and appeared in the Summer 2017–2018 edition of QAS
Insight Magazine. It is reproduced here in its amended form
with permission. Members of the media covered the official launch of the bike team in November 2017.

www.jems.com jUNe 2018 | JEMS 43

1806JEMS_43 43 5/14/18 8:05 AM

 Treating the Ebola outbreak in
West Africa
By Elvis Timothy Ogweno, MPH, MSc, EMT-P
W
orking in EMS on an Ebola
mission means you’re the first
contact with the patient and the
family. What you tell them matters a lot.
When visiting a contaminated home, our
team, which consists of a driver, two hygien-
ists, one paramedic, and one psycho-social
nurse, has to perform both donning
AL
N AT I O N
(i.e., putting on) and doffing (i.e.,
taking off ) our personal protective
equipment (PPE) in the field.
ER
Before entering the house, we run
through a PPE checklist: Scrubs, gum
boots, gloves, Tychem suit, mask, hood,
apron, goggles, and gloves (again).
“Ready?” I ask the hygienist assisting me.
She shakes her head and grabs a small strip
of duct tape, covering the space between my
hood and goggles where a thin slice of skin
was showing.
“Now you’re ready,” she replies.
The temperature in most parts of Liberia
is just over 80 degrees F. The humidity is even
higher. I feel the sweat collecting between my
skin and the suit, pooling in my boots and
along the bottom of my goggles as I slowly
44 JEMS | JUNE 2018
1806JEMS_44 44
follow the one of the hygienists, who’s also
dressed in full PPE, into the patient’s house
(i.e., the high-risk zone).
It feels far more like we’re scuba diving
in a hot spring than a conducting a normal
inter-facility ambulance transfer in the city,
but that’s exactly what we’re doing.
JEM A few moments later, I meet my
suspected Ebola patient, a young man
S
who had wandered away from his bed
ARTIC
during the night and is now lying on
LE
I NT the ground near the edge of the bed.
He’s tired and confused. He doesn’t
know where he is, or why there are two men
in what look like space suits towering over him.
The hygienist with me calmly reassures him,
and together we help lift him to his feet and
guide him back to his thin mattress.
He’s profoundly weak, and, as we walk, I
notice that his pants are soaked through with
diarrhea—a hallmark of the disease.
We lay him down and urge him to drink
some water mixed with oral rehydration salts.
I begin to complete a patient care report
(PCR) to find out if the patient meets the
case definition.
Ogweno and his team brought as many as 25 patients
a day to the ETU. Photos courtesy Elvis Ogweno
I then see another patient crawling in the
next room, and I assume it’s a relative of the
patient I’m currently diagnosing.
It seems that, by sharing their belongings,
food, and living so close together, the whole
household has been infected.
I start to feel exhausted from the heat, but I
can’t give up because I need to finish the com-
plete assessment and diagnosis before we load
the patient into the ambulance for transfer to
the Ebola treatment unit (ETU).
I minimize communications with the
patients to save energy and start using hand
signals to communicate with my teammate.
The rest of the team, not dressed in full
PPE, remain outside the house at a distance
(i.e., the green zone). However, we maintain
communications if we need assistance or addi-
tional equipment.
After diagnosis, the three patients are led
into the ambulance (i.e., the red zone). With
every step the patient takes, the hygienist
sprays chlorine to kill the virus.
From a distance, the psycho-social nurse
talks to the patients and explains where we’re
taking them and what will happen at the des-
tination. He also encourages the patients to
continue drinking water—an important com-
ponent of Ebola care.
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5/14/18 8:05 AM
 The rest of the family is left behind as we
start our journey back to the ETU.
After finishing our transport of the three
family members, they’re handed over to the
awaiting ETU nurse and the ETU’s hygienist
team—all of whom are dressed in full PPE.
Finally, the team cleans the ambulance and
then leaves it to dry, so we’re ready for the
next call.

EBOLA RAPID RESPONSE TEAM

In August 2014, I signed up with International
Medical Corps, a U.S.-based non-governmen-
tal organization (NGO), to lead a team des-
ignated for transporting both suspected and
confirmed Ebola patients and blood speci- Ogweno training the Ebola rapid response team how to survive the heat while wearing full PPE.
mens in Liberia.
When I arrived in Liberia and was assigned though, if you asked any global health expert Ebola alone didn’t cause catastrophe in
to be the ambulance coordinator of the first about the diseases that keep them up at night, West Africa. Fear played a part in it as well.
two-ambulance team on Sept. 15, 2014, I Ebola wouldn’t have made their list. Every day in Liberia, I heard stories about peo-
became a pioneer in the transport of suspected What makes Ebola different from so many ple dying of perfectly treatable diseases, since
Ebola patients. other public health threats is the effect it has many hospitals and clinics had shut their doors:
This was also the date that the second Ebola on healthcare providers, and, as a result, on A woman in labor who bled to death; a baby
treatment center was opened in the country. the entire healthcare system. half-delivered due to the lack of a midwife; a
My team would travel via helicopter to the
most remote villages to treat sick people who
couldn’t otherwise get treatment. We also used
ground-modified double-cabin pick-up trucks
as ambulances.
Within two hours of our arrival in a village,
we would set up a rapid isolation unit to iso-
late the suspected patients, and keep the rest
of the village safe from being infected.
No one knew how to transport an Ebola
patient; it was trial and error. I had to make
sure every one of my staff was safe. I dressed
in PPE every day, and would go out into the
field to show my staff how to do the job, and
show them that they could trust me to keep
them safe.
We stood by our training and our policies
and everyone stayed safe.
Our operations were carried out only during
daylight hours, due to the risks of driving at
night and having to put on PPE without ade-
quate lighting.
On an average day in West Africa, we would
bring as many as 25 suspected Ebola patients
to the ETU within 10 hours.

IMPACT ON
HEALTHCARE PROVIDERS
For decades now, Ebola has captured the pub-
lic’s imagination with its exotic name, high
fatality rate, and the fear that it can cause peo-
ple to bleed from odd places. Until recently, Ogweno dressed in full PPE, ready to enter the red zone.

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1806JEMS_45 45 5/14/18 8:05 AM

 EPIDEMIC OF FEAR
Ogweno with the Ebola rapid response team.
driver who crashed his truck and was left to
die because there was no functioning trauma
center; a young child who seized and died from
malaria—after his mother had visited multiple
hospitals and clinics, all of which were closed.
To put it bluntly, Ebola kills EMTs, para-
medics (referred to in most African countries
as “ambulance attendants”), nurses and doc-
tors, almost preferentially.
This shouldn’t be surprising; Ebola is spread
by contact with the body fluids of symptom-
atic patients—and nobody has more contact
with the body fluids of sick people than med-
ical personnel.
The toll that Ebola has taken on clinicians
A suspected Ebola patient is loaded into a makeshift ambulance.
46 JEMS | JUNE 2018
1806JEMS_46 46
and public health professionals alike means
that the very people who once calmed their
patients’ fears, who assured us that everything
was going to be okay if we only kept calm and
did as directed, were now running scared them-
selves, and that’s frightening indeed.
Ebola, though, isn’t all that frightening. It
can be destroyed with weapons as simple as
chlorine, alcohol, soap, detergent and sunshine.
With the right precautions in place, includ-
ing protective equipment and triage proto-
cols to identify those most likely to have
the disease, healthcare workers can safely
treat patients of all types without the fear of
dying themselves.
Ultimately, the local EMTs, paramedics,
nurses and doctors bore the brunt of this epi-
demic, working long hours responding and car-
ing for desperate patients without the proper
protection, watching as their colleagues fell ill
around them. The vast majority of them were
more than willing to come back to work once
their safety was ensured by the introduction of
protective equipment and protocols.
When the public saw healthcare providers
saving lives, unafraid to treat Ebola patients,
they were suddenly more willing to bring
themselves and their loved ones to the hos-
pital early, before the disease had a chance
to spread.
When transmission stopped, the epidemic
stopped, and life in West Africa returned
to normal.
As brave and heroic as they are, there sim-
ply weren’t enough trained EMTs, paramed-
ics, doctors and nurses in West Africa to stem
the tide of this epidemic on their own. And
because the necessary protective equipment
is expensive, the impoverished countries of
West Africa couldn’t afford it on their own,
and sought support from NGOs like ours.
ELIJAH
When the Ebola outbreak was at its height in
Liberia, I met a 12-year-old boy named Elijah.
A call had come into the ETU around 4 p.m.
regarding a sick boy who’d been waiting for
an ambulance for more than a day.
Despite the fact that the call had come in
past the daylight curfew for deploying ambu-
lance teams, we decided it was important to
pick up the young patient immediately.
After a five-hour drive to the small village,
we arrived to find that Elijah was displaying
the classic symptoms of Ebola.
After dressing in PPE, I diagnosed him,
completed the PCR and loaded the patient in
the ambulance. We arrived back to the ETU
around 1 a.m., where Elijah later tested pos-
itive for Ebola.
I felt a special responsibility for the young
boy. Every day, I would dress up in full PPE
and enter the ETU to make sure he was eating
and taking his medications. If he hadn’t eaten
that day, I sat with him and helped him eat.
I was impressed by Elijah’s steady improve-
ment; it gave me more motivation to go out
and help the needy every day. Within a few
days, he started to sit outside in the sun, and
a few days after that, he was running around
in the yard.
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5/14/18 8:05 AM
 After three weeks, we did another test,
which came back negative. Elijah was a survi-
vor. He was soon discharged to go back home.
On the day he was discharged, he told me
that he had heard that a person infected with
Ebola could receive the blood of an Ebola
survivor and be cured.
I explained the science behind this process
to him. He told me, ‘If you ever get Ebola, I’ll
volunteer to give my blood to save your life.’’
It was the most memorable moment for
me throughout the entire outbreak.
NO CONDITION IS PERMANENT
There was a dire need for the international
community to stop treating this crisis like a
horror movie—closing its eyes tightly until
the scary part is over—and instead treat it
like a real humanitarian disaster that required
an adequate input of monetary, logistical and
human resources.
A sufficient supply of experienced interna-
tional aid workers, including EMTs, paramed-
ics, nurses, doctors, epidemiologists, sanitation
engineers, lab technicians and logisticians, pro-
vided with the proper protection and resources,
could have brought this particular crisis to a
halt in a matter of months.
It’s true that most humanitarian emergen-
cies can’t be solved by humanitarians alone, but
the Ebola crisis in West Africa was an excep-
tion to the rule. JEMS
Elvis Timothy Ogweno, MPH, MSc, EMT-P, is the direc-
tor of operations for Partners in Health. He’s a tactical
combat paramedic with experience in critical advanced
and trauma life support techniques, hostile environment
emergency medicine, and infection prevention and con-
trol. He’s also the director of a tactical search and rescue
team. During his career in EMS, he’s responded to disas-
ters and other humanitarian catastrophic emergencies in
more than 20 countries.
When visiting a contaminated home, the Ebola rapid
response team has to perform both donning (i.e, put-
ting on) and doffing (i.e., taking off) PPE in the field.
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1806JEMS_47 47
Ebola Myths and Facts
Myth #1: Ebola is universally fatal.
Ebola can certainly be fatal, but not univer-
sally so. The case fatality ratio for Ebola and its
close cousin, the Marburg virus, varies greatly
depending on the setting.1 The first recorded
outbreak of these diseases, which occurred
in Germany and Yugoslavia in 1967, had a
mortality rate of 23%. This is high by any
standard, but far lower than the 53–88%
mortality seen in subsequent outbreaks in
sub-Saharan Africa over the next 40 years.2, 3
This first outbreak also occurred before
anything was known about the disease, and
before the widespread availability of EDs in
Europe. When it comes to the likelihood of
dying from any disease, geography matters.
Myth #2: Ebola isn’t treatable.
There are actually several effective treatments
for Ebola that can help support individuals
through the worst phases of the disease and
increase their chance of survival. These treat-
ments include early and careful resuscitation
with IV fluids; blood products such as packed
red blood cells (PRBCs), platelets, concentra-
tions of clotting factors to prevent bleeding;
antibiotics to treat common bacterial co-in-
fections, respiratory support with oxygen (in
severe cases, via a ventilator), and powerful
vasoactive medications to counter the effects
of shock. Modern diagnostic equipment can
help doctors and nurses continuously track
vital signs to rapidly detect and manage new
complications of the disease and stay one step
ahead of the virus. Access to emergency and
critical care services could help save patients
with Ebola, as well as those affected by these
and many other more common killers.
Myth #3: Ebola is the most contagious
disease, and will spread rapidly across the
U.S. if it enters the country.
Ebola isn’t the most contagious disease known.
It’s not airborne and it’s not spread by aerosols
(small droplets that float through the air). This
makes it less contagious than a host of other
diseases, such as measles, chicken pox, tuber-
culosis, or even the seasonal flu. To the best of
our knowledge, Ebola is spread only by close
physical contact, especially with bodily fluids.
So, unless someone on the subway vomits,
defecates, or bleeds on you, they aren’t going
to be passing Ebola onto you.
In a medical setting, all that’s required to
prevent the spread of Ebola from patient to
healthcare provider to patient is the use of
“contact precautions,” which include gowns,
gloves and regular hand-washing after every
patient contact.
These precautions are already the standard
in the intensive care units of all U.S. hospitals
where patients with Ebola would be treated.
Myth #4: We need to give experimental
Ebola drugs to as many Africans as possi-
ble to help stem the outbreak.
Any human given an experimental treatment
that hasn’t yet been proven safe and effective in
humans is, by definition, being experimented
upon. Experimenting on humans, even those
in poor countries, isn’t necessarily a bad thing.
Conducting research in resource-limited
settings is part of what I do for Partners in
Health. However, every person enrolled
in a medical research study is entitled to
the same basic international ethical protec-
tions—and people in poor countries actually
deserve special protections.
Myth #5: Nothing can be done to help
Africa—it’s just too poor.
The true tragedy of the Ebola outbreak is that
most Africans lack access to the very same
medications, equipment, and skilled physi-
cians and nurses that have been available in the
U.S. and Europe for several decades. Access to
these things could have prevented the current
epidemic from raging out of control.
These very same measures could also be
used to reduce mortality from the variety of
other diseases, aside from Ebola, currently kill-
ing Africans each day.
REFERENCES
1. About Marburg hemmorhagic fever. (Dec. 4, 2013.) Centers for
Disease Control and Prevention. Retrieved May 3, 2018, from
www.cdc.gov/vhf/marburg/about.html.
2. Mboup S, Musonda R, Mhalu F, et al: HIV/AIDS. In Jamison DT,
Feachem RG, Makgoba MW (Eds.), Disease and mortality in
sub-Saharan Africa, 2nd edition. The World Bank: Washington,
D.C., 2006.
3. The leading causes of death in Africa in 2012. (Oct. 31, 2014.)
Africa Check. Retrieved May 3, 2018, from africacheck.org/
factsheets/factsheet-the-leading-causes-of-death-in-africa/.
jUNe 2018 | JEMS 47
5/14/18 8:05 AM
 HOT PRODUCTS
FROM EMS TODAY 2018
30 INNOVATIVE NEW PRODUCTS
SHOWCASED AT EMS TODAY: THE JEMS
CONFERENCE & EXPOSITION
To earn the coveted title of a JEMS Hot Product, a prod-
uct has to be not only innovative, but practical. Our team
of eight judges at this year’s EMS Today Conference
and Exposition consisted of EMS product specialists,
physicians, educators, managers and paramedics. The
team reviewed a host of product contenders—from vehi-
cles to equipment to mobile apps to training aids—all
released within the 12 months before the conference.
Each judge reviewed products designed to not only
improve your ability to deliver optimal emergency med-
ical care to sick and injured patients, but also allow
EMS agencies to do it safely, more efficiently and with
enhanced comfort for the patient.
48 JEMS | JUNE 2018
1806JEMS_48 48
This year, the EMS Today Hot Products review team
reviewed and rated 64 products submitted by 52 com-
panies. Each product was rated on a 1–5 scale in four
distinct categories:
>>Originality;
>>Functionality;
>>Ease of use; and
>>Need in the EMS or prehospital setting.
Their selection of the 30 hottest products at EMS
Today 2018 are presented here in alphabetical order
by company.
Additional coverage of other products will appear in
upcoming JEMS Hands On columns.
www.JEms.com
5/14/18 8:02 AM
 5.11 Tactical
www.511tactical.com
866-451-1726
The 5.11 Stryke EMS Pant is uniquely constructed with Flex-Tac mechanical
stretch fabric and a comfort waistband to allow for unrestricted movement and
a relaxed fit. Available in a wide range of men’s and women’s sizes, each pair
includes 18 EMS mission-specific pockets and features a stain- and soil-resistant
Teflon finish.

Agency360
www.agency360.com
888-360-4289
Agency360 Field Training Software helps you to easily ensure that new
hires are trained to your agency’s own standards. Based on feedback from
thousands of users, the entire system was rebuilt from scratch. The new ver-
sion will simplify your documentation, improve consistency, centralize your
paperwork and can be operated from wherever you are. With a mobile- and
tablet-responsive design, notifications give instant access to trainee problems
and graphical reports help identify trends to support decision-making.

BEARiatrics Inc.
www.beariatrics.com
541-889-9009
The BEAR Stair Chair harness makes it possible to move extra large patients from
small and tight places while safely reducing patient and provider anxiety. With
version 2, the BEAR Stair Chair now fits under and attaches to the bottom of a Ferno
or Stryker stair chair seat. The patient sits on the seat, the side wraps are deployed
from the bottom, the device comes up and supports what gravity is pulling off the
chair seat.

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 Braun Industries Inc.
www.braunambulances.com
800-222-7286
MasterTech FleetConnect is the first ambulance-specific connectivity platform
designed to lengthen vehicle life, reduce unplanned downtime, and empower
remote maintenance and troubleshooting of a vehicle in real time. Get 24/7 remote
support from your dealer network and Braun to diagnose vehicle issues and reduce
downtime. Monitor the chassis and engine network for preventive and predictive
maintenance, and monitor and update the electrical system inside the ambulance.

Certa Dose Inc.

www.certadose.com
844-477-8607
Certa Dose Color-Coded Dosing System offers midazolam for sedation (501(k)
pending) with its revolutionary new technology that’s designed to confirm the
correct dose for all ages, empowering paramedics with confidence when deliv-
ering medications to patients in critical situations. The Certa Dose system lets the
user quickly verify a dose and help prevent dosing errors before medications reach
the patient.

Digitcare Corporation
www.digitcare.net
888-287-2990
The APEXPro XP100 Nitrile Exam Glove was developed in response to concerns
about potential synthetic opioid exposures. The glove’s black exterior offers opti-
mized contrast to readily identify the presence of powders. In addition, the APEXPro
XP100 incorporates Digitcare’s 2-ply technology for maximum glove strength as
well as their balanced pH interior coating for improved hand health.

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 Fit Responder
www.fitresponder.com
888-529-0921
Injury Free University is a validated train-
ing system that aims to prevent the additional
financial and human costs that accompany pain,
injury, overtime and poor provider wellness. The
training system was designed to support safe-
ty, injury prevention, nutrition, sleep hygiene,
patient handling, pain management and equip-
ment use, and it aims to reduce training time
while improving training accuracy.
Achieve total
responder wellness
Put the industry’s only validated, evidence-based learning system to work for you!
The FitResponder System was built for every EMS, Fire and Industrial responder
team to empower them to safely prevent injury and promote total wellness.
Developed by Injury Prevention Systems,
your trusted partner for more than 10 years
www.FitResponder.com

Genlantis
www.first-responder.com
858-457-1919
The FirstResponder Sterilizer Series utilizes triatomic oxy-
gen generator technology and UV-C rays to clean and sterilize
your gear, clothing, and any other potentially contaminated
surfaces. The self-contained mobile sterilizers are efficient, pro-
grammable and able to kill MRSA, C. difficile, norovirus, the flu
and hundreds of pathogens. The sterilizer series includes hand-
held lamps for spot cleaning, duffel bags and handheld units.

H&H Medical Products

www.gohandh.com
800-326-5708
The H*VENT Chest Seal overcomes common issues with traditionally vented chest
seals. The seal is uniquely designed with six ports that allow for multi-directional
drainage towards gravity, which facilitates that ability to transport patients on
their side.

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 ImageTrend Inc.
www.imagetrend.com
888-469-7789
Anxiety, burnout, depression, PTSD and suicide are widespread among EMS personnel and
other first responders. The free CrewCare Mobile App brings mental health awareness to
the individual user as well as the EMS industry. Users can understand their stress load, rec-
ognize common stress triggers, document mood and associated activities, and connect with
local and national support resources The non-identifiable aggregate results and analyses
provide insight for the individual user as well as the entire EMS industry.

IndeeLift Inc.
www.indeelift.com
1-844-700-5438
The IndeeLift HFL-500-E is a patient lift and transport tool for EMS
personnel on medical emergency and lift-assist calls. With a stowed
footprint of 8" x 20" x 33" and weight of 50 lbs., these units fit on
all emergency apparatus. A lift capacity of 500 lbs., coupled with
a detachable stair tread system, makes this tool one of the most
versatile tools in the EMS arsenal under $6,000.

Inovytec Medical Solutions

www.inovytec.com
+972-9-7794135
The Ventway Sparrow is an emergency ultra-portable ventila-
tor, used for transport, EMS and military applications. It’s com-
pact size and light weight makes it ideal for first responders with
limited triage capabilities who need a simple yet highly effective
self-sufficient ventilator.

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 Integra Connect
www.integraconnect.com
800-742-3069
Integra Connect delivers a comprehensive, end-to-end revenue cycle
solution for EMS—from dispatch to cash collections. Their technology-
enabled services are complemented by a proprietary, rules-based claims
engine; robust analytics enabling reporting and performance optimiza-
tion; and agile electronic data interchange capabilities. Integra Connect’s
solutions work with clients’ existing systems to increase and accelerate
cash flows.

iSimulate
www.isimulate.com
1-877-947-2831
REALITi is a new simulation ecosystem incorporating a patient simulator and
video debriefing in a single system. It can be configured to mimic proprietary
monitors, such as the ZOLL X-series and LifePak 15, and features streaming
video and live voting features, dynamic 12-lead ECGs and the ability to adapt
and grow based on your simulation needs.

Kussmaul Electronics
www.kussmaul.com
800-346-0857
The Super Auto Eject Deluxe Covers are built for severe duty and designed
for emergency vehicles. The display (either bar graph or digital) incorporates
the Auto Eject and an Indicator in one product. They’re sealed against the envi-
ronmental elements with a pre-molded rubber rear gasket, and they have a lid
that opens 180 degrees to provide more variability to plug in the shoreline. The
indicator is easy to see with 10 bars of red LED or three numerical digits showing
the status of the charger.

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 Laerdal Medical
www.laerdal.com
877-LAERDAL
With the Little Anne QCPR, the classic Little Anne manikin now includes mea-
surement and feedback technology that takes the guesswork out of instruction
using free apps downloaded onto smartphones and tablets. Little Anne QCPR
can monitor up to six manikins at once with the Instructor app, and students can
monitor their own performance with the Learner app. Little Anne QCPR improves
quality, efficiency, and engagement in community CPR training.

Nasco Healthcare
www.simulaids.com
800-431-4310
The Heartisense Premium Kit allows you to turn any CPR manikin into a smart
CPR manikin. The kit’s sensors can be attached to any manikin lacking CPR feedback
functionality and allows the Heartisense app to give you real-time feedback. The
kit works with all manufacturers’ CPR trainers and can control up to six manikins
simultaneously. All training and assessment data are digitally saved, and an online
learning management system is available to ensure accurate and effective training
and assessment.

PerSys Medical
www.ps-med.com
713-723-6000
The Blizzard Rescue Jacket is a full-length jacket with sleeves and hood. It has a
front opening and features bungee cord fastening at the bottom for heat retention.
The jacket is windproof and waterproof, making it suitable for outdoor rescues,
mass evacuations and decontamination procedures. Made from Reflexcell material,
the Blizzard Rescue Jacket offers unmatched thermal retention and is an effective
tool in the prevention and treatment of hypothermia.

54 JEMS | JUNE 2018 www.JEms.com

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 Physio-Control, now part of Stryker
www.stryker.com
425-867-4000
HealthEMS is a patient-based, protocol-driven electronic patient
care record (ePCR) system that makes documentation and crit-
ical operational processes as effortless as possible. Version 6.22
maintains the system’s powerful reporting tools and enhances the
MobileTouch ePCR application by adding new stroke scoring options:
LAPSS, RACE and VAN. The new triage/MCI functionality allows you
to capture multiple patient records tied to the same call.

Pulsara
www.pulsara.com
877-903-5642
Pulsara enables real-time communication across
healthcare entities, uniting teams across commu-
nities, helping them drastically reduce treatment
times for STEMI and stroke patients. With the
release of Pulsara 7.0, users can create dedicated
patient channels, build custom teams, and com-
municate all the way through the hospital for any
condition: trauma, sepsis, cardiac arrest, precipitous
delivery, transplant, and more.

The PulsePoint Foundation

www.pulsepoint.org
616-724-4256
PulsePoint Verified Responder is a professional version of the
award-winning PulsePoint Respond mobile app, which aims to increase
bystander response to cardiac emergencies. Verified Responder allows
PulsePoint-connected communities to alert off-duty professionals of near-
by cardiac arrest victims in both public and private/residential locations,
which account for the majority of out-of-hospital cardiac arrests.

www.jems.com jUNe 2018 | JEMS 55

1806JEMS_55 55 5/14/18 8:03 AM

 Quality in Flow (QinFlow) Inc.
www.qinflow.com
228-383-1439
The Warrior Blood and IV Fluid Warmer eliminates the challenge of warming
blood and IV fluids across the entire continuum of emergency care (i.e., prehospital
and hospital). It warms near-freezing fluids to body temperature within seconds,
even at high flow rates (up to 200 mL/min). A single rechargeable battery can warm
up to 5 L of fluids. The Warrior can be mounted to a pole, rail or stretcher. It’s practi-
cally a maintenance-free device, with five years between service cycles.

Rescue Essentials
www.rescue-essentials.com
719-539-4843
Rapid casualty evacuation from active shooter scenes continues to be a challenge.
The QuikLitter Lite was developed to provide responders a highly compact rescue
litter that can fit into most uniform cargo pockets. This allows rescue task force
members and providers to effectively bring multiple litters to the scene and into
hot and warm zones for rapid casualty evacuation.

SAM Medical
www.sammedical.com
503-639-5474
Engineered for rapid application, the SAM XT Extremity Tourniquet was designed
to normalize the number of windlass turns needed, enabling an easier, faster training
of the product and intuitive use. The TRUFORCE buckle technology auto-locks at a
predetermined amount of circumferential force, eliminating nearly all tourniquet slack.
Simply click, twist and secure for a lifesaving tourniquet application. SAM XT meets
military standards (MIL-STD 810G) for durability.

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 Skedco Inc.
www.skedco.com
503-691-7909
The new HydraSim DropLeg Bleeding Simulator
(FS-3000B-BL) allows for wirelessly detonated hem-
orrhage simulation, and also doubles as a usable
DropLeg first aid kit. The front portion of the simulator
allows caregivers to work out of the kit, while the back
portion contains Skedco’s patented bleeding simu-
lation technology. The DropLeg bleeding simulator
provides one wound with arterial or venous blood flow
and nearly two liters of blood pumping intensity, all
while appearing as a usable first aid kit.

StethoSafe
www.StethoSafe.com
407-432-1233
The StethoSafe allows you to confidently store your stethoscope
in any backpack, case, airway, duffel or aid bag without damag-
ing your diaphragm. It’s compact, rugged and easy to use. The
included cord to easily attaches the StethoSafe to any strap, loop
or bar in a bag or case, allowing you to quickly find and remove
your operational stethoscope in seconds.

Sundance Media Group LLC

www.sundancemediagroup.com
801-201-9212
The Yuneec Commercial H520 is a drone designed with six rotor systems that allow for stable,
precise flight. The H520 offers multiple payloads for optimal performance within all spheres of
public safety: E90 high-resolution camera, E50 medium focal length camera and CGOET dual ther-
mal/RGB camera. Each are hot swap-capable for maximum convenience and minimum downtime.
Data and images are shared instantly from the ST16 Ground Station or delivered directly in 4K/2K/
HD video or 12 megapixel still images.

www.jems.com jUNe 2018 | JEMS 57

1806JEMS_57 57 5/14/18 8:03 AM

 Teleflex
www.teleflex.com
919-544-8000
The Rusch Airtraq A-390 WiFi Video Laryngoscope Camera is portable, easy-
to-use, and compatible with multiple platforms. The camera allows clinicians to
record real-time high-resolution images and video. It can store up to 200 videos
and more than 10 hours of footage. The new Airtraq A-390 Camera is almost 50%
lighter and smaller than the previous model.

TrueClot by Luna
www.trueclot.com
434-220-9444
The TrueClot Tourniquet Application Trainer is a wearable device that allows
full application of a tourniquet for training purposes. Training blood can be pumped
through the device to simulate hemorrhage, and when a tourniquet is properly
applied, bleeding is stopped. The padded arm cuff reduces pinching and pain and
allows for proper application of a tourniquet during classroom or scenario training.

UNITY EMS
www.theunityems.com
616-901-0040
UNITY EMS has developed the first and only
uniform designed specifically for EMS. Developed
for medics, by medics, these uniforms integrate
high-performance activewear and industry-spe-
cific features to maximize safety, comfort and
performance. UNITY EMS’s American-made uni-
forms reflect the pride EMS professionals take in
the work they do and the lives they save.

58 JEMS | JUNE 2018 www.JEms.com

1806JEMS_58 58 5/14/18 8:03 AM

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For more information, visit JEMS.com/rs and enter 11.

1806JEMS_59 59 5/14/18 8:03 AM

 HANDS ON
PRODUCT REVIEWS FROM STREET CREWS

Improved Automated CPR

For more than 15 years, LUCAS has automated CPR compressions and provided consistent rate, depth
and release. The upgrades in version 3.1 of Stryker’s LUCAS chest compression system allow you to adjust
setup options for compression rate/depth, pauses, alerts,
timer, and ventilation features to meet local emergency VITALS
care protocols. LUCAS 3.1 now includes Wi-Fi connectivity Dimensions (assembled): 22" x 20.5" x 9.4"
with a LIFENET system. Users can set up device readiness Weight: 17.7 lbs.
notifications, modify setup options and transmit device Battery run time: 45 mins.
reports wirelessly. Adjustable parameters include Patient size parameters:
compression rate (between 102 and 120 compressions 6.7"–11.9" (chest height),
per minute), depth (from 1.8 to 2.1 inches), piston auto- 17.7" (chest width)
lowering and pressure pad release to allow for chest rise www.physio-control.com
during ventilation. 800-442-1142

Secure Your Multi-Tool

The Leatherman multi-tool created and set the standard for a new genre of tools. The benefits of
carrying one on duty include everything from using the pliers to open an oxygen cylinder, the screw
driver to tighten a loose handle and the knife blade to cut rope during a rescue. There are many ways
to carry a multi-tool, but a new line of Leatherman Sheaths keeps your multi-tool handy. The nylon
sheath is available in three sizes to fit small, medium and
VITALS large tools. The nylon sheath with pockets is available in
Sizes: Small, medium, large medium and large sizes. The pockets can hold a bit kit for
Material: Ballistic nylon different driver bits, a small flashlight or a Sharpie marker.
Color: Black The sheaths are made of a durable, ballistic nylon with
Price: $10.00; $15.00 (with pockets) elastic and reinforced stitching for easy accessibility. A high-
www.leatherman.com grade metal rivet snap ensures your tool remains secure
800-847-8665 and the sheath lasts a long time.

VITALS
Length: 6.5"
Pocket-Sized Spot to Flood Weight: 4.4 oz.
We never know where our calls are going to
Power: 2 AA batteries
take us, and sometimes we need a flashlight at
Max output: 250 lumens
unexpected times. It’s easy to remember to bring a
Price: $35.00
large flashlight at night, but what do you have handy
www.streamlight.com
when the power goes out in the basement? The light on
800-523-7488
your cell phone may work for a few minutes, but it’s impractical, and
you certainly don’t want to run down the battery more than necessary. The new
Streamlight Jr. F Stop is a compact LED light with an adjustable beam that changes from spot
light to flood light by simply sliding the lens up or down the light’s barrel. Powered by two size
AA alkaline or lithium batteries, the Streamlight Jr. F Stop can run from six to 10 hours.

Fran Hildwine, BS, NRP, is the AHA Training Center Coordinator at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. He’s also an
EMS instructor at Good Fellowship Ambulance Club in West Chester, Pa. Contact him at fran100b@zoominternet.net.

60 JEMS | JUNE 2018 www.JEms.com

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 For more reviews: www.jems.com/Hands-On

Thermal Imaging Rescue Training

The more realistic the training scenario, the better the experience for the learner. Now
that thermal imaging cameras have dropped in price and more departments are issuing
them, the training to incorporate this search and rescue tool needs to be realistic. The new
TI Rescue Randy and TI Rescue Baby from Simulaids features heating elements in the face
and hands which are powered up by a simple 110-volt AC plug. The heating elements
reach temperature in 15 minutes and remain
effective for thermal imaging training for more VITALS
than 45 minutes. The heaters are placed in the Length: 55" (Randy), 26" (baby)
face and hands—often the only areas which Weight: 149 lbs. (Randy); 20 lbs. (baby)
are unclothed during most rescue operations. Power: 110v AC
The manikin weighs the same as a real person, Price: $2,166.50 (Randy); $1,122.00 (baby)
making the extrication require a realistic www.enasco.com
number of personnel. 800-558-9595

A Baby Designed to Save Babies

Teaching CPR to first time parents is one of the rewards of being a CPR instructor. You
get a chance to answer questions and allay some fears. Due in large part to high levels
of durability and dependability, Baby Anne from Laerdal has been part of CPR classes
for decades, and now she’s just received some major upgrades. Improvements to the
airway include revised oral and nasal passages
VITALS for more realistic ventilation, and an airway that
Length: 20" will close if hyperextended, reinforcing the need
Weight: 3.3 lbs. to maintain a neutral head position for proper
Skin colors: Light; dark ventilation. Baby Anne maintains the realistic
Price: $119.00; $445.00 (4 pack) chest compression compliance you’ve come to
www.laerdal.com expect and she still has a foreign body that can
877-LAERDAL be inserted for choking training.

Impregnated Packing
“Just pack it off.” That’s the advice Colonel Potter gives Captain BJ Honeycut in the
famous TV series M*A*S*H, now heard in operating rooms and trauma bays around
the world every day. When surgeons find diffuse bleeding in the abdominal cavity,
it often helps to use direct pressure via packing to let the body heal itself by clotting
off the blood vessel that’s bleeding. QuikClot Control+ from Z-Medica is impregnated
with kaolin, a naturally occurring, inorganic mineral
that accelerates the body’s natural clotting process. It’s VITALS
the same material that’s been used by QuikClot since Sizes: 5" x 5", 8" x 8",
2012. Available in a variety of sizes, QuikClot Control+ Z-fold (3" x 2 yards), 12" x 12"
looks and feels like a traditional gauze dressing virtually Price: Call for pricing
eliminating the learning curve and it has double X-ray www.quikclotcontrolplus.com
indicators to lessen the possibility of a retained product. 877-750-0504

IN THE NEXT ISSUE: >> Verathon GlideScope Go >> Homeland-Six Radio Strap >> ImageTrend Continuum Earth
>> FoxFury Command+ Tilt LED Headlamp >> Intercept Free 2 Tone Gloves >> Spyderco ClipiTool Rescue

www.jems.com jUNe 2018 | JEMS 61

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 FIELD PHYSICIANS
EMS DOCS’ PERSPECTIVES ON STREET MEDICINE
LIFT-ASSISTS, REFUSALS &
RELEASES
Four myths of no-loads & decisional capacity assessment
By Neal J. Richmond, MD, FACEP
A
9-1-1 call comes in for a 69-year-
old female lift-assist. The patient’s
daughter tells you that she found her
mom on the floor that morning.
According to your patient care report
(PCR): “The patient appears in no distress
and denies any complaints,” and you “assist
the patient to her walker and her chair.”
No past medical history, review of sys-
tems, or risk factors are recorded in the
PCR, and no vital signs or physical exam are
documented either.
A release at scene is called into 9-1-1 dis-
patch, and the final call disposition in the
computer-aided dispatch system lists your
unit as “cancelled.”
Several hours later, a second call comes into
9-1-1 from the same address, and this time
another crew finds the patient in cardiac arrest.
Although most lift-assists don’t typically
end this badly, calls like this one are handled
by 9-1-1 systems across the country each day.
In many instances, there’s little documentation
on the PCR—assuming one ever gets filled
out in the first place.
To put this case in better perspective, you
can do a quick back-of-the-napkin calculation.
If cardiac arrests represent approximately 1%
of 9-1-1 call volume, and approximately half
of these cases get worked, and 5–6% of them
survive, then in a system with an annual call
volume of 100,000, 25–30 patients will walk
out of the hospital alive.
Saving these 25 patients is, by the way,
something that requires extraordinary person-
nel and operational resources to accomplish,
in addition to a substantial infusion of polit-
ical and financial capital. The point is that it
takes a lot to make a difference.
No-loads, on the other hand—whether
lift-assists, refusals or releases—make up
62 JEMS | JUNE 2018
1806JEMS_62 62
about 15–70% of EMS system call volume.
If you assume a conservative 25% no-load
rate in a system with an annual call volume of
100,000, then 25,000 patients are at poten-
tial risk of getting worse—or even dying,
especially if the initial call to 9-1-1 somehow
gets mishandled.
MYTH #1: EVERYONE NEEDS
TO GO TO THE HOSPITAL
Transporting patients is a good way to stay out
of trouble and keep reimbursement rates up.
On the other hand, it doesn’t take too much
to imagine that there aren’t a whole lot of
patients who really need an ambulance or an
ED, especially for what are often primary or
chronic care complaints. The trick is to figure
out which ones don’t need to go.
Whether or not we think a patient is hav-
ing a true emergency, it’s our job to deter-
mine whether that individual has decisional
capacity to make an informed refusal of con-
sent—not in general, but in this one partic-
ular instance of a call to 9-1-1. This means
that patients have to be able to communicate
their wishes, as well as their understanding of
the risks and consequences of refusing treat-
ment or transport.
MYTH #2: YOUR PATIENT HAS TO
BE ALERT & ORIENTED X 3 OR 4
Although patients should be awake or alert
enough to communicate, most of us often
have no idea what day it is in the middle of
our own busy, often sleep-deprived work week.
What our patients should be able to demon-
strate, though, is their understanding, insight
and judgment—something that even a mildly
demented patient might be able to do by hav-
ing a conversation with you.
In contrast, just because patients are alert
and oriented doesn’t automatically mean they
have decisional capacity.
Acutely decompensated schizophrenics
typically know what day it is, but they may
also think your stethoscope is a direct commu-
nication link to the spaceship you landed in.
MYTH #3: MOST 69-YEAR-OLD
FEMALES ON THE FLOOR ARE
EMTS OR PARAMEDICS
Since most patients aren’t EMTs or paramed-
ics, it’s our job to explain to them the risks
and consequences, and do so in language they
can understand before they can communicate
their understanding back to you.
You also can’t assume they understand
when they say “yeah” or “OK” or “I’ll be fine.”
They must be able to explain everything back
to you in their own words.
MYTH #4: TELLING PATIENTS THEY
MIGHT DIE IS GOOD ENOUGH
Telling your patients they might die if they
don’t go to the ED just doesn’t cut it.
Instead, you have to come up with some
kind of differential diagnosis to explain why
the patient may have gone to ground. Maybe
the patient is uroseptic or cracked a hip, had
a stroke or cardiac dysrhythmia, or is hypo-
glycemic or hyperkalemic.
That means not just putting the patient
back in bed, but taking a brief history, check-
ing vital signs, performing a vectored physi-
cal exam, and looking at things like an ECG,
oxygen saturation, end-tidal CO2, or finger
stick glucose. JEMS
Neal J. Richmond, MD, FACEP, is board
certified in emergency medicine and med-
ical director for the MedStar Mobile Health-
care System in Fort Worth, Texas. 
www.JEms.com
5/14/18 8:05 AM
 DOES YOUR CAREER
NEED RESUSCITATION?
4 STEPS TO GIVE YOUR
CAREER A PULSE
1. Visit JEMS Jobs
2. Upload your resume
3. Save time searching by location,
categories and keywords
4. Make your next crew your family

For more information, visit JEMS.com/rs and enter 12.

AD INDEX

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Bound Tree Medical IFC 1 Isimulate IBC 13

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Fire Station Outfitters 14 7 Junkin Safety 17 8

First Responder 9 5 Masimo OBC 14

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www.jems.com jUNe 2018 | JEMS 63

1806JEMS_63 63 5/14/18 8:05 AM

 LAST WORD
THE UPS & DOWNS OF EMS

An ECG pattern of normal sinus rhythm appears to be projected in the shadows of Brian LaCroix’s vineyard. Photo courtesy Brian LaCroix

A CLOSER LOOK
Most people know Brian LaCroix as the president/EMS
chief for Allina Health EMS, based in St. Paul, Minn., which
serves more than one million people annually with a team of more
than 600 caregivers.
What many don’t know is that LaCroix is also a very accomplished
artist and photographer. Recently, while tending to the vineyard on his
property in Hastings, Minn., his artistic and photographic perspectives
captured an amazing photo.
A closer look at the vineyard reveals what appears to be normal
sinus rhythm projected in the shadows.
We give LaCroix a thumbs up for producing another beautiful work
of art, but also for his outstanding leadership in building Allina Health
EMS into a well-respected organization within the EMS industry and
the community his agency serves.
which saw an additional 20 EMS volunteers join the ranks of the orga-
nization in that city. In addition, United Hatzalah inaugurated a new
ambulance that will be present at all times in the heart of the Jewish
community in the city.
In August 2017, United Hatzalah opened a chapter in Ukraine, its
fifth country in ongoing efforts to expand its international operations
for communities around the globe.
We give a thumbs up to all of the new graduates and recognize
their willingness to serve the emergency medical needs of their com-
munity. JEMS

CARE IN THE UKRAINE

A moving ceremony took place in early February in the cen-
tral Chabad house of Kiev in Ukraine, as 20 new volunteer
EMTs graduated from their lengthy training program and will now
be joining United Hatzalah’s worldwide network of EMS volunteers.
The EMT first responders will provide first aid and EMS coverage
to all medical emergencies that take place in the Jewish communities
in and around Kiev and throughout Ukraine. New EMS graduates pose in Chabad house in Kiev, Ukraine. Photo courtesy United
A few days later, a graduation ceremony took place in Uman, Ukraine, Hatzalah

JEMS (Journal of Emergency Medical Services)® (ISSN 0197-2510) USPS 530-710, JEMS is published 12 times a year, monthly by PennWell® Corporation, 1421 S. Sheridan Rd., Tulsa, OK 74112.
Periodicals postage paid at Tulsa, OK 74112, and at additional mailing offices. SUBSCRIPTION PRICES: Send $20 for one year (12 issues) or $30 for two years (24 issues) to JEMS, 26395 Network Place,
Chicago, IL 60673-1263 or call toll free 800-869-6882. International callers, please dial +1 512-982-4277. Canada: Send $30 for one year (12 issues) or $50 for two years (24 issues). All other foreign
subscriptions: Send $60 for one year (12 issues) or $100 for two years (24 issues). Single copy: $10.00. POSTMASTER: Send address corrections to JEMS (Journal of Emergency Medical Services) , P.O.
Box 47570, Plymouth, MN 55447. Claims of non-receipt or damaged issues must be filed within three months of cover date. JEMS is a registered trademark. © PennWell Corporation 2018. All rights
reserved. Reproduction in whole or in part without permission is prohibited. We make portions of our subscriber list available to carefully screened companies that offer products and services that
may be important for your work. If you do not want to receive those offers and/or information via direct mail, please let us know by contacting us at List Services JEMS (Journal of Emergency Medical
Services), 1421 S. Sheridan Rd., Tulsa, OK 74112. Printed in the USA. GST No. 126813153. Publications Mail Agreement no. 40612608.

64 JEMS | JUNE 2018 www.JEms.com

1806JEMS_64 64 5/14/18 8:06 AM

 For more information, visit JEMS.com/rs and enter 13.

1806JEMS_C3 3 5/14/18 8:06 AM

 Taking Noninvasive Monitoring
to New Sites and Applications ™

EMMA™ Rad-57® MightySat™ Rx

Capnograph Handheld Pulse CO-Oximeter® Fingertip Pulse Oximeter

EtCO 2 RR SpO 2 PR Pi SpMet ®

SpCO
®
SpO 2 PR Pi

For over 25 years, Masimo has been an innovator of noninvasive patient

monitoring technologies, striving to improve patient outcomes and reduce
the cost of care.

Masimo offers leading technology to care providers across the continuum

of care — including mobile settings, Emergency Medical Services (EMS),
and other post acute care areas.1

For more information, visit www.masimo.com

PLCO-001806/PLMM-10817A-0418

Caution: Federal (USA) law restricts this device to sale by or on the order of a
physician. See instructions for use for full prescribing information, including
indications, contraindications, warnings, and precautions.
PLLT-10356C

© 2018 Masimo. All rights reserved.

1
Not all Masimo products are intended for use in all care areas.

For more information, visit JEMS.com/rs and enter 14.

1806JEMS_C4 4 5/14/18 8:06 AM