The Pros and Cons of Degree Requirements for Paramedics: Kazan and Moy debate

Should paramedicine require a minimum degree? In this post, two EMS physicians, Clayton Kazan (Medical Director for LA County Fire Department) and Hawnwan P. Moy (Medical Director for ARCH Air Methods in Missouri) , debate the Pros and Cons.

CON: Raise the Roof, Not the Floor.

by Clayton Kazan MD FACEP FAEMS

Far be it from me to knock the benefits of higher education.  It was always one of my narcissistic goals to achieve more letters after my name than in it, and, with the addition of FAEMS this year, I have finally achieved it.  I think that the “associations,” as they describe themselves in the PEC published joint statement (NEMSMA, NAEMSE, IAFCCP), are going about this the wrong way, and the detrimental effects on paramedic programs, particularly fire-based programs, will be severe. [1]  I have been involved in training EMTs and paramedics since 1995 (again with the narcissism), and I would be a huge supporter of this concept if I believed that this was the gap between poor and good (or good and great) prehospital clinicians…that, if only they had fulfilled the general education courses needed to finish their degree, they would be given the tools they need to build strong clinical skill.  By the same argument, I am a better physician today because of the undergraduate coursework that I completed at my alma mater (UCLA).  So, linguistics (my textbook was a freaking dictionary), psychology (rats given dopamine will forego food and sex to get it), art history (pyramids at Giza = cool) are really part of the fabric that makes me an amazing clinician (yup) today?  Even my science courses had very limited applicability…unless the human body has a xylem and phloem, or I am ever asked to synthesize a perfume that smells like bananas.  If you think that these types of courses would not be required of our paramedics, then I invite you to review the A.S. requirements of a junior college. [2]  I took the EMT course as a sophomore specifically because my coursework had NO relevance to my chosen field, and the rest is history.

The issue we have as we strive to develop an EMS profession is not the prerequisites that our paramedics bring as they start their careers, it’s that it is a dead end.  Requiring an A.S. degree does not change that.  The position statement states that 60% of paramedic programs already offer an Associate’s or Bachelor’s degree program is misleading because, using their source, only 1.6% currently offer Bachelor’s. [3]    If you want to take those Associate’s Degrees and use them toward a Bachelor’s, how many of the universities are giving course credits for the paramedic program and not requiring the students to start from scratch with introductory biology, physiology, etc.?  In California (because the west coast is the best coast), the answer is zero.  Thus, the Associate’s is a dead end, and that is part of the reason why many students do not continue their education to finish their degree. 

What is missing in our prehospital clinicians is the opportunity and encouragement to be lifelong learners, to stay in EMS, and to advance past paramedic.  Build the degree programs so their paramedic certificate is worth something to them from a career advancement perspective.  Requiring an A.S. of everybody may raise the floor, but it definitely does not raise the ceiling.  Build bridges within the house of medicine to use that credit towards a nursing, PA, or, dare I say it (I dare, I dare), a medical degree…so our providers don’t feel chained to their ambulance or squad for the duration of their career.  Rather than knocking our current programs back to EMT-I (BTW not recognized in Cali), build an advanced paramedic level with an expanded scope of practice, as we have for our flight programs.  What our profession needs is a carrot, not a stick.

Lastly, I want to comment (rant) on a statement made near the end of the article… “From an economic standpoint it is almost certain that degree requirements will restrict the supply of available paramedics to some extent.”  For fire-based EMS systems, this represents a disastrous, unfunded mandate that will severely affect the supply of available paramedics.  They are right that it creates an upward surge in salary, but their argument that this money will come from third party payers and local governments is ludicrous.  Requiring paramedics to have degrees will not squeeze one penny out of health insurers, local government budgets are nightmarish without this.  To me, “the associations” have not clearly thought through what stream actually fills this imaginary pool of money they think will pay for this.  As huge constituents of the schools and employers of the graduates, it is essential that fire-based EMS provider stakeholders have a voice in the future direction of paramedic programs, and I urge our membership to read their reply.4

References

1.     Sean M. Caffrey, Leaugeay C. Barnes & David J. Olvera (2018) Joint Position Statement on Degree Requirements for Paramedics, Prehospital Emergency Care, DOI: 10.1080/10903127.2018.1519006

2.     Illinois Central College. www.icc.edu.  https://icc.edu/academics/catalog/associate-in-science/associate-in-science-degree-requirements/.  Accessed January 5, 2019.

3. Programs CoAEMSP. Find a Program 2018; Selected Paramedic, Accredited, All States and Provinces with boxes checked for associates, bachelors and masters compared to all chek boxes (inclusive of certificate and diploma). 2019. Available at: https://www.caahep.org/Students/Find-a-Program.aspx. Accessed January 5, 2019.

4. Fire Service EMS. www.fireserviceems.com. http://fireserviceems.com/joint-position-statement-opposition-to-proposed-degree-requirements-for-accredited-paramedic-programs/. Accessed January 7, 2019.

PRO: A Good Build Starts with a Strong Foundation

by Hawnwan P. Moy, MD FAEMS

I’ll start by stating that Dr. Kazan and I are friends.  Like all traditional friendships, we embrace our similarities and poke fun at our disagreements.  I dare not break tradition. While Dr. Kazan MD FACEP FAEMS #SpoiledinCali (sorry @PEMEMS) believes that requiring further education for paramedics is all for naught, I believe this is a crucial step in creating a better trained, more prepared and well-rounded paramedic. 

Critical thinking is essential to practicing excellent paramedicine.  What defines a great paramedic is NOT what procedures they can do, but how they think.  No offense to any 12-year-old, but we can teach any 12 year old how to intubate.  But to teach a 12-year-old when to intubate, when to anticipate a bad airway, or whether they should intubate requires critical thinking.  “Critical thinking is that mode of thinking — about any subject, content, or problem — in which the thinker improves the quality of his or her thinking by skillfully analyzing, assessing, and reconstructing it.” [4] Paramedic educators have the responsibility to teach the fundamentals of paramedicine.  Yet they rarely have enough time to build a foundation for critical analysis. This is where creating education requirements for paramedics is paramount.  

In order to engender critical thinking, a solid foundation must be established beyond high school education.  A foundation of critical thinking has to be broad to expose the mind to different ways of thought. So while I agree that linguistics (I can’t believe you took Latin @Clayton_Kazan), psychology (Maslow’s Hierarchy of needs is important, but listen to Ginger Locke’s Hierarchy of needs here!) and art history (pyramids, schmyramids...The Great Wall is so much cooler) have a low correlation to actual clinical medicine, the underlying benefits of challenging the mind to think differently, to understand the world from different viewpoints, to learn from history’s lessons, to understand different ways to achieve the same goal, provides an invaluable foundation to critical thinking.  

 Let me utilize someone from Dr. Kazan’s beloved California as an example, Steve Jobs.  Yes, Steve Jobs didn’t finish college. However, he did enroll in at least a year of college where he had to take general basic courses that had nothing to do with computers.  One such course was calligraphy (see Steve Job’s Standford Graduation Speech).  In the 70’s, the world of computers only had Atari-like block font.  Yet it took someone like Jobs who had experience in calligraphy, an appreciation for design, and the critical thinking to apply calligraphy to computers to revolutionize the world of technology.   Just look at this very webpage you’re reading. All those different fonts evolved from Steve Jobs’ influence. As he said, “…you can’t connect the dots looking forward; you can only connect them looking backward.  So you have to trust that the dots will somehow connect in your future. You have to trust in something your gut, destiny, life, karma, whatever.” So while I agree that taking general education courses may have little relevance to the field of medicine, they do create a foundation for critical creative thinking and may even create unique solutions. 

On that note, I do not believe that an associates degree is a dead end, but a beginning of a journey.  Dr. Kazan is correct in that the sources he cited, only 1.6% of programs currently offers Bachelor’s degree.  Technically speaking requiring a Bachelor’s degree would provide a stronger base, but for those who face real-life challenges where time is not a luxury, a two years Associate’s degree is a good start.  30/50 states have some sort of guarantee of transferring credits to a Bachelor's degree.  

Nonetheless, Dr. Kazan speaks some truth.  Encouraging a love of learning in your paramedics and paramedic advancement are key to job satisfaction.  I think it is great when paramedics gain additional medical training beyond paramedicine to become a physician assistant or physician, but not all paramedics want to leave the job - and we don’t want them to.  I know plenty of paramedics who are in the field because they love what they do and don’t want jobs that take them within four walls. I agree paramedics should have a career ladder. However, that ladder should be based not only on experience but education.  Just look at our fire brethren who require further education - a Bachelor’s (or Masters!) in Fire Science-for advancement in their career. You’re right Dr. Kazan, paramedics do need a carrot and our paramedics deserve to be paid more for their work. That can be justified by a required education needed to become a paramedic.  Nurses did it with their profession. [3,8]  Why can’t we?  

To follow up on the supposed financial catastrophe that the number of paramedics will fall precipitously due to education requirements, let’s look at other states who have paramedic education requirements, Kansas and Oregon1.  Those states have enacted education requirements and guess what?!?!  EMS continued to march on. Yes, change is scary. We have every right to be anxious.  Maybe this will initially affect the number of paramedics enrolling in our systems. Yet looking at these two states as examples, proves that a possible decrease in paramedics will not last indefinitely.  

In the end, Dr. Kazan and I are two sides of the same coin.  Despite our differences (one of the main ones being I’m better-looking :P), we believe in education and care deeply for the future of paramedicine and paramedics.  He works in a successful EMS system and is one of the grittiest, dedicated EMS medical directors I know. I do not fault his comments. In fact, I encourage it. I thank him for it.  It creates thoughtful conversation, a lively debate, and dare I say it a valuable viewpoint that forces you, the reader, to critically think about your own thoughts on education requirements for paramedics.  See what I did there? So, Dr. Kazan, I raise my glass to you and I just have one thing to say to your impending retorts. I know you are, but what am I?

To hear a lively debate about this very issue, check out our PEC podcast discussion here!

References

1. Caffrey, Sean M., et al. “Joint Position Statement on Degree Requirements for Paramedics.” Prehospital Emergency Care, vol. 23, no. 3, 2018, pp. 434–437., doi:10.1080/10903127.2018.1519006.

2. JoshuaG. “Steve Jobs Stanford Commencement Speech 2005.” YouTube, YouTube, 6 Mar. 2006, www.youtube.com/watch?v=D1R-jKKp3NA.

3. Kutney-Lee, Ann, et al. “An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality.” Health Affairs, vol. 32, no. 3, 2013, pp. 579–586., doi:10.1377/hlthaff.2012.0504.

4. “Our Concept and Definition of Critical Thinking.” Our Conception of Critical Thinking, www.criticalthinking.org/pages/our-conception-of-critical-thinking/411.

5. “PEC Podcast.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/pec-podcast-6.

6. “Prehospital Emergency Care Podcast Ep. 58.” Prehospital Emergency Care Podcast - the NAEMSP Podcast, pecpodcast.libsyn.com/prehospital-emergency-care-podcast-31.

7. “Resource Title:50-State Comparison: Transfer and Articulation Policies.” Education Commission of the States, www.ecs.org/transfer-and-articulation-policies-db/.

8. Smith, Linda S. “Said Another Way: Is Nursing an Academic Discipline?” Nursing Forum, vol. 35, no. 1, 2000, pp. 25–29., doi:10.1111/j.1744-6198.2000.tb01175.x.

Feel The Heat: Managing Exertional Heat Stroke

by Mark Liao, MD, NRP (@EMSDocMark)

Expert Peer Review by Dorothy Habrat, MD (@EMSDrDorothy)

Clinical Scenario

A 25-year-old male is brought to your Finish Line medical station. Bystanders noted that he was unsteady on his feet while running a half-marathon before he collapsed. The outside conditions are notable for an air temperature of 22.7 °C (73 °F) and a humidity of 45%, which subjectively feels quite mild to you. The patient does not respond to questions properly, is pale and diaphoretic. Once inside the medical station tent, his skin does not feel hot when his forehead is touched and is otherwise moist. A tympanic membrane thermometer registers an aural temperature of 36.7 °C (98 °F). The patient is persistently confused and a rectal thermometer is subsequently utilized, which registers 41.1 °C (106 °F).

Review

Exertional Heat Stroke (EHS) is an environmental medical emergency from excessively high body core temperature due to physical exertion. National surveillance data for annual prevalence is difficult as these cases are included with classic heatstroke seen in the elderly [1] or reported alongside other types of exertional heat illness such as heat exhaustion [2,3]. Typical risk groups for EHS include athletes (particularly high school football players [4]) and military personnel. In 2018, the US Armed Forces experienced 578 cases of EHS for soldiers on Active Duty during global operations and training [5] . EHS is also a particular concern for medical planners involved in large sporting events: an 8-year study at the Indianapolis Mini Marathon identified 32 cases of EHS among over 235,000 combined participants [6]. Recognizing the need for early and aggressive treatment of EHS, the National Association of EMS Physicians published an important consensus statement in 2018 that outlines the identification and management of EHS in the pre-hospital setting which will be reviewed here [7].   

Identification of EHS

While Exertional Heat Stroke is typically associated with hot conditions, it can still occur in cooler climates.

EHS should be considered if an individual has been performing physical activity and experiences central nervous system disturbance. This can range from irritability or confusion to decreased level of consciousness. Delays in EHS recognition are multifactorial. Counterintuitively, EHS can still occur in cooler weather despite its association with hot climates [8]. It is a common misconception that EHS patients will have stopped sweating.   Patients, when touched, may not always feel warm and may even feel cool with skin moisture present.

Waiting for the development of profound central nervous system dysfunction such as obtundation or unconsciousness may result in delayed treatment and underscores the importance for maintaining a high level of suspicion during athletic events [9].

 Inaccurate Equipment Can Result in Misidentification 

Rectal thermometers, such as the one seen here, are the only way of getting an accurate rectal temperature to recognize EHS.

The only accurate and practical prehospital method of core body temperature evaluation for EHS is to use a rectal thermometer, placed at a depth of 15 centimeters (about 6 inches) [10]. The National Athletic Trainers’ Association (NATA), like NAEMSP, similarly recommends that rectal thermometers be considered the gold standard for EHS assessment and therefore should be part of the EHS emergency treatment plan for athletic programs [11] . As such, EMS providers should be educated on these thermometers being used prior to ambulance arrival. Once inserted, the rectal thermometer should be left in place for continuous monitoring during cooling efforts and transport. Many rectal thermometers used in the hospital setting are only inserted 1.5 centimeters into the rectum and therefore are not accurate enough for EHS assessment [12]. Temporal artery thermometers, ear/tympanic membrane thermometers, and oral thermometers are not accurate in the detection of EHS and should not be used [13-15].

(A) Hospital thermometers probes (left) generally are unable to be inserted into the recommended depth of 15cm (B) Clockwise from left: Temporal artery surface thermometer, oral digital thermometer, tympanic membrane thermometer and forehead infrared thermometer. These devices should not used in the evaluation of EHS due to problems with accuracy.

 Strategies for Rapid Cooling

This 50 Gallon tub is used at the Indianapolis Mini Marathon for Cold Water Immersion

Rapid cooling is the key management step of EHS. Rapid cooling should begin when the patient is symptomatic.  Based on expert consensus, if the rectal  temperature is greater than 40.5 °C (104.9 °F), Cold Water Immersion cooling should occur when available (see algorithm below), as it most expeditiously accomplishes rapid cooling.  This involves placing the patient into a tub of ice water (with enough ice to maintain a water temperature of 10 °C / 50 °F  ) and the body immersed in water from the neck down. Tubs of approximately 50-gallon capacity are generally sufficient for this task, though some programs prefer tubs of 150-gallon capacity [16]. Proper cooling techniques should result in a reduction of rectal temperature to less than 38.6 °C (101.5 °F) within 30 minutes.

Other alternatives include the use of a tarp (“tarp assisted cooling”), also filled with ice water, while the water is agitated continuously by responders to keep the cold water moving [17]. A similar technique involves using a fluid impervious body bag filled with ice water, which may be helpful in the hospital setting if no tub or tarp is available.

Other field methods of cooling

The use of ice packs placed close to arteries (neck, axilla, groin) has been taught for many years and may be one of the few practical options in an ambulance. However, this technique appears to have marginal cooling benefit when used alone and should not be used as the primary method of cooling whenever possible[18].

The US Army Training and Doctrine Command is a proponent of ice sheets as part of heat casualty response plan for trainees, which utilizes cotton sheets soaked in ice water and stored in coolers [19]. This requires placement of sheets onto as much bare skin as possible except for the face, and rotated with fresh sheets when the placed sheets start to feel warm. The technique is not as effective as cold water immersion [20].

Recommended rectal temperature thresholds to start and stop Cold Water Immersion

Evaporative cooling, such as fanning a patient or even using the rotor wash from a helicopter, appears to be significantly slower than cold water immersion in reducing body temperature [21-22]. Evaporative cooling may also be less effective in high humidity situations.

While it may seem intuitive that chilled intravenous fluids would be helpful for rapid cooling, research in this area is limited. In a small study of healthy human volunteers, chilled saline of 4 °C (39.2 °F) decreased core body temperature by only 1 °C  (1.8 °F) after 30 minutes [23]. Though using cold saline infusion in combination with other cooling modalities may improve patient outcomes [7].

Prehospital Protocol Considerations

Given the importance of rapid cooling in the setting of EHS, EMS protocols should consider prioritizing cold water immersion over transport if the equipment is available onsite; NAEMSP and NATA both recommend a “cool first, transport second” approach. Communication with the receiving hospital is essential, particularly if onsite cooling is unavailable as Emergency Departments may need to initiate cooling in non-traditional care areas such as a decontamination room. EMS providers should be reminded to consider other causes of collapse and confusion, including hypoglycemia and hyponatremia.

Prevention

Monitoring Wet Bulb Globe Temperature provides a real-time assessment of heat risk

The risk of EHS is increased in the setting of hot, humid conditions. Providers working at mass gathering or athletic events should evaluate event policies regarding adjustments to work/rest cycles, safety messaging, rest/sleeping facilities, provision of cooling devices (such as arm immersion cooling systems) and ensure appropriate EHS response equipment is available [24]. The Heat Index or Wet Bulb Globe Temperature are tools that are useful in developing an understanding of current or projected risk of heat related illness [25].

Conclusion

EHS can be effectively managed in the prehospital environment when recognized in a timely fashion. A high index of suspicion is needed anytime an athlete experiences CNS disturbance after doing physical activity: responders can be falsely reassured when the climate does not appear too warm, CNS disturbance is only mild or if the patient’s skin is not hot to the touch. A multidisciplinary approach should be taken to incorporate on-site medical personnel, such as athletic trainers, in developing protocols to ensure the coordinated management of EHS. Finally, EMS agencies should take steps to ensure the availability of equipment such as rectal thermometers and cold-water immersion supplies at local athletic centers, sporting events and military training venues.

 References

1.     Choudhary, E., & Vaidyanathan, A. (2014, December 12). Heat Stress Illness Hospitalizations — Environmental Public Health Tracking Program, 20 States, 2001–2010. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/ss6313a1.htm

2.     Yeargin, S. W., Kerr, Z. Y., Casa, D. J., Djoko, A., Hayden, R., Parsons, J. T., & Dompier, T. P. (2016). Epidemiology of Exertional Heat Illnesses in Youth, High School, and College Football. Medicine & Science in Sports & Exercise, 48(8), 1523-1529. doi:10.1249/mss.0000000000000934

3.     Yeargin, S. W., Dompier, T. P., Casa, D. J., Hirschhorn, R. M., & Kerr, Z. Y. (2019). Epidemiology of Exertional Heat Illnesses in National Collegiate Athletic Association Athletes During the 2009–2010 Through 2014–2015 Academic Years. Journal of Athletic Training, 54(1), 55-63. doi:10.4085/1062-6050-504-17

4.     Centers for Disease Control and Prevention. (2010, August 20). Heat Illness Among High School Athletes --- United States, 2005--2009. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a1.htm

5.     Armed Forces Health Surveillance Branch. (2019, April 1). Update: Heat Illness, Active Component, U.S. Armed Forces, 2018. Retrieved from https://www.health.mil/News/Articles/2019/04/01/Update-Heat-Illness

6.     Sloan, B. K., Kraft, E. M., Clark, D., Schmeissing, S. W., Byrne, B. C., & Rusyniak, D. E. (2015). On-site treatment of exertional heat stroke. Am J Sports Med, 43(4), 823-9. doi:10.1177/0363546514566194

7.     Belval, L. N., Casa, D. J., Adams, W. M., Chiampas, G. T., Holschen, J. C., Hosokawa, Y., … Stearns, R. L. (2018). Consensus Statement- Prehospital Care of Exertional Heat Stroke. Prehospital Emergency Care, 22(3), 392-397. doi:10.1080/10903127.2017.1392666

8.     Roberts, W. O. (2006). Exertional Heat Stroke during a Cool Weather Marathon. Medicine & Science in Sports & Exercise, 38(7), 1197-1203. doi:10.1249/01.mss.0000227302.80783.0f

9.     Hostler, D., Franco, V., Martin-Gill, C., & Roth, R. N. (2014). Recognition and Treatment of Exertional Heat Illness at a Marathon Race. Prehospital Emergency Care, 18(3), 456-459. doi:10.3109/10903127.2013.864357

10.  Miller, K. C., Hughes, L. E., Long, B. C., Adams, W. M., & Casa, D. J. (2017). Validity of Core Temperature Measurements at 3 Rectal Depths During Rest, Exercise, Cold-Water Immersion, and Recovery. Journal of Athletic Training, 52(4), 332-338. doi:10.4085/1062-6050-52.2.10

11.  Casa, D. J., DeMartini, J. K., Bergeron, M. F., Csillan, D., Eichner, E. R., Lopez, R. M., … Yeargin, S. W. (2015). National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. doi:10.4085/1062-6050-50-9-07

12.  Welch Allyn. (2018). Capturing Rectal Temperature. Retrieved from https://www.welchallyn.com/content/dam/welchallyn/documents/sap-documents/MRC/80022/80022620MRCPDF.pdf

13.  Ronneberg, K., Roberts, W. O., McBean, A. D., & Center, B. A. (2008). Temporal Artery Temperature Measurements Do Not Detect Hyperthermic Marathon Runners. Medicine & Science in Sports & Exercise, 40(8), 1373-1375. doi:10.1249/mss.0b013e31816d65bb

14.  Huggins, R., Glaviano, N., Negishi, N., Casa, D. J., & Hertel, J. (2012). Comparison of Rectal and Aural Core Body Temperature Thermometry in Hyperthermic, Exercising Individuals: A Meta-Analysis. Journal of Athletic Training, 47(3), 329-338. doi:10.4085/1062-6050-47.3.09

15.  Mazerolle, S. M., Ganio, M. S., Casa, D. J., Vingren, J., & Klau, J. (2011). Is Oral Temperature an Accurate Measurement of Deep Body Temperature? A Systematic Review. Journal of Athletic Training, 46(5), 566-573. doi:10.4085/1062-6050-46.5.566

16.  Zhang, Y., Davis, J., Casa, D. J., & Bishop, P. A. (2015). Optimizing Cold Water Immersion for Exercise-Induced Hyperthermia. Medicine & Science in Sports & Exercise, 47(11), 2464-2472. doi:10.1249/mss.0000000000000693

17.  Hosokawa, Y., Adams, W. M., Belval, L. N., Vandermark, L. W., & Casa, D. J. (2017). Tarp-Assisted Cooling as a Method of Whole-Body Cooling in Hyperthermic Individuals. Annals of Emergency Medicine, 69(3), 347-352. doi:10.1016/j.annemergmed.2016.08.428

18.  Gaudio, F. G., & Grissom, C. K. (2016). Cooling Methods in Heat Stroke. The Journal of Emergency Medicine, 50(4), 607-616. doi:10.1016/j.jemermed.2015.09.014

19.  Training and Doctrine Command. (n.d.). Prevent of heat and cold casualties (TRADOC Regulation 350-29). Retrieved from Department of the Army website: https://adminpubs.tradoc.army.mil/regulations/TR350-29.pdf

20.  Nye, E. A., Eberman, L. E., Games, K. E., & Carriker, C. (2017). Comparison of Whole-Body Cooling Techniques for Athletes and Military Personnel. Int J Exerc Sci, 10(2), 294-300. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360373/

21.  Armstrong, L. E., Crago, A. E., Adams, R., Roberts, W. O., & Maresh, C. M. (1996). Whole-body cooling of hyperthermic runners: Comparison of two field therapies. The American Journal of Emergency Medicine, 14(4), 355-358. doi:10.1016/s0735-6757(96)90048-0

22.  Poulton, T. J., & Walker, R. A. (1987). Helicopter cooling of heatstroke victims. Aviat Space Environ Med, 58(4), 358-61.

23.  Moore, T. M., Callaway, C. W., & Hostler, D. (2008). Core Temperature Cooling in Healthy Volunteers After Rapid Intravenous Infusion of Cold and Room Temperature Saline Solution. Annals of Emergency Medicine, 51(2), 153-159. doi:10.1016/j.annemergmed.2007.07.012

24.   DeGroot, D. W., Kenefick, R. W., & Sawka, M. N. (2015). Impact of Arm Immersion Cooling During Ranger Training on Exertional Heat Illness and Treatment Costs. Military Medicine, 180(11), 1178-1183. doi:10.7205/milmed-d-14-00727

25.  Casa, D. J., DeMartini, J. K., Bergeron, M. F., Csillan, D., Eichner, E. R., Lopez, R. M., … Yeargin, S. W. (2015). National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. doi:10.4085/1062-6050-50-9-07

EMS MEd Editor : Maia Dorsett, MD PhD (@maiadorsett)