Collateral Damage: COVID-19 and the EMS Psyche

by Jeremiah Escajeda, MD FAEMS

Our world has changed and, according to public health experts in the US, it will never be the same.

EMS continues to staff the front lines of our new reality. 

As local, national and international COVID-19 epidemiological data transforms daily, so do our local EMS protocols, policies and processes, compounding the stress that EMS professionals and first responders endure. We are in “disaster mode” as a speciality. The current pandemic has disrupted everything; our mental edge going to-and-after work, how we interact with patients and colleagues, our friends and our family. 

Some of our geographical regions are fortunate enough to not suffer the severe burden of the overwhelming influx of COVID-19 patients to our healthcare systems as hot spots in New York City already have. We have, however, changed as an international speciality, forever, because of the pandemic. The situation will continue to evolve, but the future holds many uncertainties. 

The COVID-19 pandemic presents additional challenges in our EMS community. A term we would like to call the Collateral COVID-19 Damage. (#CollateralCovidDamage). On one side, we have the physical and mental health ramifications of responding as frontline workers, on the other, the medical interventions that we deliver to all patients have changed. 

Consider three months ago. You and your partner arrive on-scene, mask-free, to an elderly patient with respiratory failure from a nursing facility who had a past medical history of decompensated heart failure and was discharged from the hospital for heart failure 7 days ago.   She is hypertensive and hypoxic.  What would you have done?  Administer some nitroglycerin and place the patient on non-invasive positive pressure ventilation (NIPPV) without hesitation. 

Now, consider that same patient scenario today. 

Are you wearing the correct personal protective equipment (PPE)? Did the PPE policy change? Did you remember to check your email for updates today? Does your agency have enough PPE? What if you are practicing in a COVID-19 hotspot? What if now your agency doesn’t allow NIPPV because of the aerosolization risk of novel coronavirus-19? What do you do with the “Do Not Intubate” status of this patient? What if this nursing facility recently had 15 positive COVID-19 cases? Should this patient be transported? What do you ask or tell the nursing facility staff members who you know are also scared about their other patients, themselves and their families? What do you tell the patient or the family (although it is likely that they won’t be present because of the COVID-19 visitor restrictions, at the nursing facility, during transport and in the hospital)? Can this patient call family members? Did you write down a phone number for their family? What if the receiving facility does not permit prehospital NIPPV from EMS because of the potential risk to hospital staff? Should you forgo NIPPV altogether, for all patients? You hear wheezing, but albuterol nebulizers are bad right? Your partner confirms this. Did you just touch your face? Do you have enough disinfectant to use at the station? At your house? What if you know that if you transport this patient that they may be intubated, without family present? What if they die alone? What if this was a 40-year-old, because you heard on the news that 40-30-20-year-olds are dying from COVID-19? What is this anti-malaria medicine everyone keeps talking about? What do you do before you go home to disinfect? What do you tell your family? What should you share with them? And what if we could just go back to three months ago?

This is the collateral COVID-19 damage. 

Having a brain full of these questions is real and it is a normal response to our chaotic, strange world and can be cognitively overwhelming. Just as we can’t go to the grocery store without a mask and a pocket full of sanitizing wipes, we can’t go to a ‘run of the mill’ EMS call without having COVID-19 concerns. This is the new normal for us, for now, but there is hope. 

State-based mitigation strategies are working. Communities, while physically distancing, are socially rallying for all frontline workers. Think about how many “thank yous” or “how are you doings” you have been hearing in recent weeks. The free coffee, food, it all helps to mitigate our own collateral covid-19 damage. What you do is valued and critical to combating this pandemic.   What you do matters. 

We would like to open the post up for you.  Give us an example of how you have found meaning or reaffirmation in your work in these difficult times.  Share a positive experience that you have encountered in the last few weeks as a frontline worker.  Either post here - or if you want - e-mail a sound or video clip, or a written story, to [email protected]. 

We will combine these into a follow-up post in the coming month. 

Wishes from my Garden: Let Us Be Antifragile

By Maia Dorsett, MD, PhD, FAEMS

Editor, @EMS_MEd

One week ago today, I had my family move out of my house and in with my parents who live around the corner.  I had read the data about healthcare workers bringing the virus home, and I could not bear the thought of bringing it home to my parents who moved close to me when they retired this year.

In this time I’ve realized, probably like a lot of other people,  that I am a much more social person that I thought I was.  I have a renewed appreciation for direct human connection – for hugging my children tight, preparing meals for my family, for going out for a cold beer and warm food with my colleagues after a long shift in the ED. When I am not at work in the ED, answering calls from my EMS agency or responding to COVID-19 emails, I feel quite lonely.  I always thought that if I had some time to myself at home I could be so much more productive, but I have found that my productivity on anything non-COVID-19 related has basically come to a halt.  My mental processors are so overladen trying to make sense of a daily torrent of changing information that I find myself cognitively slowed and unable to push through on any of the projects that I had only wished for the time to work on before.

As a mental health break, I have been going outside to puddle around in my garden. The cognitive silencing of cleaning out garden beds and weeding is strangely rejuvenating.  But more so, in my garden, I have found a sense of hope.  As I have raked away the leaves and trimmed dead stalks, everywhere there is new life emerging.  The ridiculous number of bulbs and perennials that I, after compulsively internet ordering in the wee hours of the night after ED shifts, planted in the Fall are emerging after surviving the harsh Rochester winter.  These plants did more than survive the Rochester winter, they used the cold weather to break down seed coats and start biochemical processes so that they could make their comeback stronger and more beautiful than they were in the previous year.   It is my garden that has instilled in me this wish as we enter this tidal wave: let us be more than resilient, let us be  Antifragile.  On the other side of this, whenever that may be, let us build a system better than we have today.

In recent weeks,  I have felt like I am being eaten from the inside out by frustration.  By relaxing PPE regulations that are more a response to shortage than science. By the inability to test for the disease. By wading through a sea of unknowns and feeling like everything is blurry when I want it more than anything to be clear.  By wishing I could do more to change the course of what is to come.   But I hope that we are like the perennials in a garden, taking this time to sew roots that will make us stronger and better in the future.   Let this be a time of great innovation and recognition of the importance of emergency preparedness and public health.  With a proverbial winter upon us, I see the signs of these fragile roots emerging all around us: recognition of EMS as frontline healthcare, alternative destinations, hospital cooperation to reduce ED volumes, change in production lines, adaptability and more.  

While it feels lonely with my family out of the house, I have also never in my career felt a stronger sense of togetherness – of a shared purpose with amazing, dedicated and selfless people who truly care for those around them.

The weight is heavy, but we will lift it together.  Let us be stronger on the other side.

Maia Dorsett is an Emergency Medicine and EMS Physician, wife, daughter, sister, mother of 3 and fellow human being residing and working in Rochester, New York.  Priorities not in that order.

Article Bites #17: PARTing the Confusion on Airway Selection in Out-of-Hospital Cardiac Arrest

The Article:

Wang HE, Schmicker RH, et al. (2018). Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest. JAMA, 320(8), 769.

doi:10.1001/jama.2018.7044

Background & Objectives:

Airway management has long been one of the first steps in the ABC’s of cardiac arrest management, but there has recently been growing evidence that early definitive airway management may not necessarily lead to improvement of meaningful outcomes.  In 2018, there were 3 landmark papers published in JAMA that attempted to shed light on which method of airway management was better in out-of-hospital cardiac arrest (OOHCA).

• Trial 1 – BVM vs ETI, where use of BVM compared with ETI failed to demonstrate noninferiority or inferiority for survival with favorable 28-day neurological function. [1]
  

• Trial 2 – i-Gel SGA vs ETI (AIRWAYS-2), where randomization to a strategy of advanced airway management with a supraglottic airway compared with tracheal intubation did not result in a favorable functional outcome at 30 days. [2]  (See Article Bite #14 for more in-depth discussion of this trial: http://www.naemsp-blog.com/emsmed/2019/9/14/article-bites-14-to-tube-or-not-to-tube-in-cardiac-arrest)

So, we essentially have a scientific “tie” between BVM vs ETI and i-Gel vs ETI with respect to their primary outcomes studied (although I strongly suggest you read the secondary outcomes and decide for yourself).  However, like in sports and politics, we attempt to declare a winner in the end, and the question about which method of airway management is best cannot be left in this state of uncertainty.

Enter the third published trial of 2018, where Henry Wang et al sought to determine the effect of King-LT vs endotracheal intubation on 72-hour survival in adult OOHCA.

Methods:

This was a multicenter, pragmatic, cluster-crossover, open-label, randomized trial involving 27 EMS agencies across the US in 13 clusters, with clusters crossing over at 3-5 month intervals.

• Patients: Adults (18+) with non-traumatic OOHCA requiring ventilatory support or advanced airway management

• Intervention: Initial airway management with King-LT

• Comparison: Initial endotracheal intubation (ETI)

  • Protocol allowed for use of paralytics and video laryngoscopy

  • Protocol allowed for airway rescue attempt with any technique if the initial attempt was unsuccessful, but did not limit the number of attempts

• Outcome

  • Primary: 72-hour survival

  • Secondary: ROSC, survival-to-hospital discharge, favorable neurologic status at hospital discharge (mRS </= 3), and key adverse events

Key Results:

• 3004 enrolled patients between December 1, 2015 and November 4, 2017

  • Initial King-LT – 1,505 patients

  • Initial ETI – 1,499 patients

View fullsize

Takeaways:

This trial demonstrated that the King-LT is faster to attempted airway placement (by an average of 2.7 minutes) and required fewer insertion attempts for successful airway placement, which could have implications in improved CPR quality and thus the improved primary and secondary outcomes, although this trial did not measure CPR quality specifically.

Furthermore, this trial did demonstrate statistically significant differences in 72-hour survival, ROSC, survival-to-hospital discharge, and favorable neurologic status at discharge with the King-LT compared to endotracheal intubation.

The initial ETI success rate of 51.6% is much lower than previously published studies, and could be multi-factorial.  A primary reason could be that many EMS medical directors encourage earlier use of the supraglottic airway to avoid multiple intubation attempts, in order to avoid chest compression interruptions.

What This Means For EMS:

On the surface, it seems that we finally have a “winner”, that the King-LT leads to improved meaningful outcomes compared to endotracheal intubation in adult OOHCA.  However, on further examination, it seems that we are comparing this supraglottic device to a strategy which utilizes inferior endotracheal intubation skills, given the ETI first-pass success rate of 51.6%, with 20% of patients requiring 3 or more airway attempts.

We cannot assume that this low success rate was due to inadequate training, although that may have been the case.  As many of us with EMS backgrounds know, it could be due to the complexity of the environment, the acuity of the patients, or a lack of experience.

Even if we made the assumption that the first-pass ETI success rate would improve with increased training, and spent a ton of time and money training and buying fancy equipment and improve our first-pass ETI success, AIRWAYS-2 showed us that there was no difference in favorable neurologic outcomes at 30 days with i-Gel (87.4% success rate) vs ETI (70% success rate).  Ultimately, we would spend a lot of time, money, and energy to achieve a “no difference” between the strategies.

Even in the Jabre study, they had physicians working in EMS systems who were very skilled in intubation, and there was still no significant difference in their intubation vs use of a simple BVM in 28-day neurologic outcome.

Some might argue that the reason for improved primary and secondary outcomes with the King-LT is because the CPR quality was probably higher, since you could easily deduce that the airway was faster and easier to place, and with fewer attempts overall.  However, we must be careful because this study did not specifically measure this.

What the accumulated studies are showing us is that the management of the airway during cardiac arrest is of minimal clinical consequence, and can often become a distraction from the things that would improve survival in cardiac arrest, such as emphasis on high-quality CPR and early defibrillation…you know, the basics.

Recognizing that intubation is becoming a high-risk, low-frequency prehospital skill that is expensive and complex to maintain proficiency, these recent studies do not support the costs of maintaining this skill.

Perhaps it is time to do a randomized controlled trial comparing nasal cannula with a jaw thrust, BVM with capnography, i-Gel, King-LT, and endotracheal intubation, and maybe we can finally put this argument to rest?

Ultimately, when you are working your next adult OOHCA, you should employ the airway strategy for which you are most efficient, or which is the simplest and fastest, limiting distractions and interruptions in CPR, focusing on the basics and fundamentals, which likely are the interventions that truly matter in achieving those meaningful patient outcomes.

References:

1.    Jabre P, Penaloza A, et al. (2018). Effect of Bag-Mask Ventilation vs Endotracheal Intubation During Cardiopulmonary Resuscitation on Neurological Outcome After Out-of-Hospital Cardiorespiratory Arrest. Jama, 319(8), 779. doi: 10.1001/jama.2018.0156

2.    Benger JR, Kirby K, et al. (2018). Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome. Jama, 320(8), 779. doi: 10.1001/jama.2018.11597

Article Bites Summary by: Brandon Morshedi, MD, DPT (@bbmorshedi)

BLS is more than basic, it’s fundamental to good care.

by Erin Brennan, MD, MPH

Recently on twitter, one of our colleagues, Joshua Stilley, an EMS Physician, tweeted the following:

His description suggests an important change in our lexicon.  The way we describe things assigns value – and basic implies that it is easy to do and sounds much less attractive that “advanced”.  But there is a large body of evidence that suggests that not only is BLS care is fundamental to good outcomes, but that some aspects of “advanced” care can distract/detract from the “fundamentals” that really make a difference to patients.

OPALS

The 800-pound gorilla of literature on this topic is the Ontario Prehospital Advanced Life Support (OPALS) Study [1-5], which is a must read for any EMS physician or professionals.  The OPALS study was a before and after study which examined patient outcomes before and after the introduction of advanced life support with the province of Ontario, Canada.  The OPALS investigators focused on three conditions: cardiac arrest, major trauma and respiratory distress.

Cardiac Arrest

The OPALS investigators enrolled 5638 patients: 1319 consecutive patients in a 12-month rapid defibrillation (basic life support) phase and 4247 in an advanced-life-support phase of their study. [3] Their primary study outcome, rate of survival to hospital discharge, did not improve significantly when they moved from the rapid-defibrillation phase to the advanced life support phase (5.0 percent to 5.1 percent, P = 0.83). [6] They did see improvement in rates of ROSC (12.9 percent to 18.0 percent, P < 0.001) and survival to hospital admission (10.9 percent to 14.6 percent, P <0.001) but no increase in the number of survivors with good neurologic outcome (cerebral performance category 1) (78.3 percent vs 66.8 percent, P = 0.83). [3]

Despite the lack of evidence for the effectiveness of advanced life support in out of hospital cardiac arrest, Phase I of the OPALS trial highlighted the importance of other components of the chain of survival including EMS response intervals, bystander CPR, CPR by police or fire and early defibrillation. [6].  After optimization of BLS defibrillation the Ontario community saw a rise in OHCA survival from a previously published 2.5% to 3.5% overall. [6] The strength of the OPALS study is in the large number of patients enrolled across a variety of community settings. Although, none of the settings could be considered rural and applications of these findings to a rural population may not produce the same outcomes.

The findings from the OPALS trial are consistent with those of an observational cohort study of a sample of Medicare beneficiaries who experienced OHCA done by Sanghavi et al.  from 2009 – 2011. [7]  The authors found that survival to hospital discharge was greater in those treated by BLS (13.1% v 9.2%). [7]  90 day survival (8.0% vs 5.4% ) and neurologic function among hospitalized patients (21.8% vs 44.8%) were also found to be greater in the BLS group. [7]

The question is why?  While there are certainly confounders that can be considered, subsequent work has found no to minimal benefit for “core” ALS-specific interventions such as epinephrine, anti-arrhythmics, or endotracheal intubation in cardiac arrest for neurologically-intact survival in adult patients who have suffered OHCA. [8-11]  It is possible that, in the absence of prioritization of interventions, the “availability” of such ALS interventions interferes with the most fundamental components of resuscitation from out of hospital cardiac arrest by EMS – early defibrillation and quality compressions.

Major Trauma

The data is compelling for BLS care in cardiac arrest but is it the same in severe trauma?  The OPALS study investigated whether ALS care (endotracheal intubation, IV fluid administration) improved survival to hospital discharge in patients with recent traumatic injury (less than 8 hrs) and an injury severity score greater than 12.  [1] They found no substantial difference in survival to hospital discharge between BLS an ALS care (81.8% for BLS v 81.1% for ALS). In fact, in those with GCS <9 ALS care increased mortality (60.1% v 51.2%). The reasoning for this may be due to delayed hospital transport while ALS interventions are performed on scene or complications of endotracheal intubation.  A meta-analysis by Lieberman et al performed before the publication of the OPALS trauma study came to the same conclusion - there is no benefit to on-site ALS intervention for patients with major trauma. [12]  The authors also postulate that the delay in definitive care to perform ALS interventions on scene is the underlying cause of the findings. A more recent study by Rappold et al evaluated survival in patients with penetrating trauma in an urban environment who were transported via ALS, BLS or police. [13] Their findings are consistent with previous data.  They found the overall adjusted OR identified a 2.51-fold increased odds of dying if treated with ALS care.  The outcomes of these studies emphasize that definitive care for severely injured trauma patients is most likely to be in the operating room rather than on the side of the highway.  Additionally, as our knowledge evolves about the effect of permissive hypotension in trauma patients, the findings supporting BLS care as optimal make more and more sense. [14,15]

Respiratory Distress

There is evidence supporting the importance of BLS care in severely injured trauma patients and patients experiencing out of hospital cardiac arrest, but does the BLS vs ALS difference hold true for respiratory distress? OPALS evaluated the addition of ALS interventions to a BLS life support system and found an overall decrease in death rate of 1.9 percentage points for patients admitted to the hospital. [2] However, deaths in the Emergency Department were unchanged.  Interestingly, even in the ALS phase of the study, ALS crews only responded to 56% of the calls and ALS interventions were rarely used even then (endotracheal intubation 1.4%, IV medication administration 15%). There was a large increase in medications used for symptom relief (15.7% to 59.4%) and an increase in the paramedic evaluation of patient improvement during transport (24.5% to 45.8%).  With the addition of CPAP to the BLS scope of practice, the need for ALS level care for patients in acute respiratory failure may be changing.  A meta-analysis by Williams et al in 2013 pooled data from 5 studies representing just over 1000 patients.  They found a significant decrease in the number of intubations (odds ratio 0.31) and deaths (odds ratio 0.41) in the CPAP group [16].   

Beyond OPALS

Understandably, OPALS did not study every prehospital diagnosis.  Indeed, there are time sensitive illnesses where ALS-level of care makes a difference in patient outcome.   

Myocardial Infarction

The ability to perform,  interpret a 12 lead EKG, prenotify and transport to the correct destination can shorten the door-to-balloon time resulting in smaller infarct size and reduction in morbidity and mortality. [17-19].  The benefit for these patients seems to come from the ability to communicate critical EKG findings to the hospital. This can be done by paramedic interpretation and radio report or BLS EKG acquisition and transmission to the hospital for physician interpretation.   

Sepsis

A King County based study evaluated the effect of IV catheter placement and IV fluid resuscitation in patients with severe sepsis and found decreased hospital mortality for both subsets of patients. [20] The authors hypothesize that, as in MI, the benefit for patients may be related to early hospital notification and aggressive early ED management of these patients in addition to prehospital fluid resuscitation.  Subsequent studies have identified benefit for fluid resuscitation itself in septic patients who present with initial hypotension [21]

The Crashing Patient

The best outcome from a cardiac arrest is the one that was prevented from happening in the first place.  In an effort to reduce the incidence of EMS-witnessed cardiac arrest, recent research from Pinchalk et al out of Pittsburg EMS looked at a critical care bundled “stay and play” package for EMS providers to stabilize critically ill medical patients in an attempt to reduce the incidence of post EMS contact cardiac arrest. [22] This research is not yet published but is exciting. Care providers in this urban EMS systems were encouraged to stay on scene until the critical care objective were met.  These objectives include aggressive management of the airway and respiratory distress/failure, aggressive management of hypotension and management of underlying dysrhythmias.  This protocol emphasizes the importance of BLS care initially in managing the airway with BVM and OPA/NPA with advanced airway placement done after fluid resuscitation and dysrhythmia management. After the initial BLS airway maneuvers ALS care become necessary with IV/IO insertion and dysrhythmia recognition and management as well as initiation of vasopressors where appropriate. With implementation of this critical care bundle, Pittsburgh EMS saw a decrease in the rate of post EMS contact cardiac arrest from 12.1% to 5.8% (p = 0.0251).  This care bundle is now part of the statewide EMS protocols in Pennsylvania.

Take Home Points

The standard of EMS care has evolved over time towards ALS level care in many communities around the world.  To justify the cost of maintaining this level of care and skill for providers there should be considerable improvements in patient oriented outcomes such as neurologically intact survival after out of hospital cardiac arrest and decreased morbidity and mortality after major trauma.  The results of several large studies question the benefit to ALS interventions when BLS care is optimized.  Review of the literature suggests that an understanding by EMS systems and providers of what interventions lead optimal outcomes is more complex than just the distinction between BLS and ALS care.  Some patients will benefit from advanced interventions such as fluid resuscitation and dysrhythmia management, while others require rapid transport to definitive care in the operative suite. While the issue of what level of care is best for each individual patient is far from settled, it is clear that the prehospital phase of care for all patients is critically important for outcome.

EMS MEd Editor, Maia Dorsett, MD PhD FAEMS

References

1.     Stiell, I. G., Nesbitt, L. P., Pickett, W., Munkley, D., Spaite, D. W., Banek, J., . . . for the OPALS Study Group. (2008). The OPALS major trauma study: Impact of advanced life-support on survival and morbidity. CMAJ : Canadian Medical Association Journal = Journal De L'Association Medicale Canadienne, 178(9), 1141-1152.

2.     Stiell, I. G., Spaite, D. W., Field, B., Nesbitt, L. P., Munkley, D., Maloney, J., . . . OPALS Study Group. (2007). Advanced life support for out-of-hospital respiratory distress. The New England Journal of Medicine, 356(21), 2156-2164.

3.     Stiell, I. G., Wells, G. A., Field, B., Spaite, D. W., Nesbitt, L. P., De Maio, V. J., . . . Lyver, M. (2004). Advanced cardiac life support in out-of-hospital cardiac arrest. N Engl J Med, 351(7), 647-656.

4.     Stiell, I. G., Wells, G. A., Spaite, D. W., Lyver, M. B., Munkley, D. P., Field, B. J., . . . DeMaio, V. J. (1998). The ontario prehospital advanced life support (OPALS) study: Rationale and methodology for cardiac arrest patients. Annals of Emergency Medicine, 32(2), 180-190.

5.     Stiell, I. G., Wells, G. A., Spaite, D. W., Nichol, G., O’Brien, B., Munkley, D. P., . . . Anderson, S. (1999). The ontario prehospital advanced life support (OPALS) study part II: Rationale and methodology for trauma and respiratory distress patients. Annals of Emergency Medicine, 34(2), 256-262.

6.     Stiell, I. G., Wells, G. A., DeMaio, V. J., Spaite, D. W., Field, B. J., Munkley, D. P., . . . Ward, R. (1999). Modifiable factors associated with improved cardiac arrest survival in a multicenter basic life support/defibrillation system: OPALS study phase I results.

7.     Sanghavi, P., Jena, A. B., Newhouse, J. P., & Zaslavsky, A. M. (2015). Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Internal Medicine, 175(2), 196-204.

8.     Perkins, G. D., Ji, C., Deakin, C. D., Quinn, T., Nolan, J. P., Scomparin, C., . . . PARAMEDIC2 Collaborators. (2018). A randomized trial of epinephrine in out-of-hospital cardiac arrest. The New England Journal of Medicine, 379(8), 711-721.

9.     Kudenchuk, P. J., Brown, S. P., Daya, M., Morrison, L. J., Grunau, B. E., Rea, T., ... & Larsen, J. (2014). Resuscitation Outcomes Consortium–Amiodarone, Lidocaine or Placebo Study (ROC-ALPS): Rationale and methodology behind an out-of-hospital cardiac arrest antiarrhythmic drug trial. American heart journal, 167(5), 653-659.

10.  Benger, J. R., Kirby, K., Black, S., Brett, S. J., Clout, M., Lazaroo, M. J., ... & Smartt, H. (2018). Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. Jama, 320(8), 779-791.

11.  Wang, H. E., Schmicker, R. H., Daya, M. R., Stephens, S. W., Idris, A. H., Carlson, J. N., ... & Puyana, J. C. J. (2018). Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-of-hospital cardiac arrest: a randomized clinical trial. Jama, 320(8), 769-778.

12.  Liberman, M., Mulder, D., & Sampalis, J. (2000). Advanced or basic life support for trauma: Meta-analysis and critical review of the literature. The Journal of Trauma: Injury, Infection, and Critical Care, 49(4), 584-599.

13.  Rappold, J. F., Hollenbach, K. A., Santora, T. A., Beadle, D., Dauer, E. D., Sjoholm, L. O., . . . Goldberg, A. J. (2015). The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment. The Journal of Trauma and Acute Care Surgery, 79(3), 343-348.

14.  Silbergleit, R., Satz, W., McNarnara, R. M., Lee, D. C., & Schoffstall, J. M. (1996). Effect of permissive hypotension in continuous uncontrolled intra-abdominal hemorrhage. Academic Emergency Medicine, 3(10), 922-926.

15.  Wiles, M. D. (2017). Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? Anaesthesia, 72(12), 1448-1455.

16.  Williams, T. A., Finn, J., Perkins, G. D., & Jacobs, I. G. (2013). Prehospital continuous positive airway pressure for acute respiratory failure: A systematic review and meta-analysis. Prehospital Emergency Care, 17(2), 261-273.

17.  Kobayashi, A., Misumida, N., Aoi, S., Steinberg, E., Kearney, K., Fox, J. T., et al. (2016). STEMI notification by EMS predicts shorter door-to-balloon time and smaller infarct size. The American Journal of Emergency Medicine, 34(8), 1610-1613.

18.  Kontos, M. C., Gunderson, M. R., Zegre-Hemsey, J. K., Lange, D. C., French, W. J., Henry, T. D., . . . Garvey, J. L. (2020). Prehospital activation of hospital resources (PreAct) ST-segment-elevation myocardial infarction (STEMI): A Standardized approach to prehospital activation and direct to the catheterization laboratory for STEMI recommendations from the american heart association's mission: Lifeline program. Journal of the American Heart Association, 9(2), e011963.

19.  Shavadia, J. S., Roe, M. T., Chen, A. Y., Lucas, J., Fanaroff, A. C., Kochar, A., ... & Bagai, A. (2018). Association between cardiac catheterization laboratory pre-activation and reperfusion timing metrics and outcomes in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A report from the ACTION registry. JACC: Cardiovascular Interventions, 11(18), 1837-1847.

20.  Seymour, C.W., Cooke, C.R., Heckbert, S.R. et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. Crit Care 18, 533 (2014).

21.  Lane, D. J., Wunsch, H., Saskin, R., Cheskes, S., Lin, S., Morrison, L. J., & Scales, D. C. (2018). Association between early intravenous fluids provided by paramedics and subsequent in-hospital mortality among patients with sepsis. JAMA network open, 1(8), e185845-e185845.

22.  Pinchalk, M., Palmer, A.,  Dlutowski, J., Mooney, J., Studebaker, A., Taxel, S., Reim Jr., J., Frank, P. (2019) Utility of a prehospital “crashing patient” care bundle in reducing the incidence of post EMS Contact cardiac arrest of critically ill medial patients.

Article Bites #16: TXA: The Future for Stop the Bleed?

TL;DR

• TXA is used to stabilize clots by preventing fibrinolysis

• Dose: 1g over 10 minutes, then 1g over 8 hours

• CRASH-2 has shown an improvement in survival

  • Even greater improvement if administered within 3 hours (earlier is better!)

• CRASH-3 has shown mortality improvement in mild-moderate isolated head trauma (GCS 9-15)

• TXA rate of vascular occlusive events = placebo rate of vascular occlusive events

• Consider adding TXA to pre-hospital protocols as an adjunct to stop the bleed

The Articles:

The CRASH-2 Collaborators, Shakur H, et al. (2010). Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet, Vol 376 (Issue 9734), 23-32. doi: 10.1016/S0140-6736(10)60835-5

The CRASH-2 Collaborators, Roberts I, Shakur H, et al. (2011). The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomized control trial. Lancet, Vol 277 (Issue 9771), 1096-101. doi: 10.1016/S0140-6726(11)60278-X.

The CRASH-3 Collaborators. (2019). Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): A randomized, placebo-controlled trial. Lancet. Vol 394 (Issue 10210), 1713-1723. doi: 10.1016/S0140-6736(19)32233-0.

Background:

If you recall the clotting cascade, the end of the process involves the breakdown of clots (also known as fibrinolysis), through the activation of plasminogen to plasmin. Tranexamic acid (TXA) is a synthetic form of lysine, an amino acid. TXA is used to block fibrinolysis by attaching to plasminogen and blocking the fibrin binding site, preventing the formation of plasmin. Historically, TXA has been used in the operating room to stabilize already formed clots to prevent worsening bleeding.

Naturally, the next step is to see whether the drug can prevent bleeding in other settings besides the O.R. In this article bite, we will discuss CRASH-2 and CRASH-3 – two large studies on the efficacy of TXA in trauma.  

CRASH-2 Methods:

CRASH-2 was a randomized double-blinded control study involving 20,211 patients across 274 hospitals in 40 countries. The study group had the following inclusion criteria:

• Adult trauma patients

• Significant hemorrhage

  • Hypotension with systolic blood pressure < 90 mmHg and/or

  • Tachycardia with heart rate > 110

• At risk for significant hemorrhage

• Within 8 hour of injury

In addition, the study excluded cases where giving TXA was the obvious clinical choice. This exclusion allowed the researchers to focus on patient care guided by the uncertainty principle (ie. when the risk/benefit was less clear). Patients were randomized to either receive normal saline or TXA 1g infused over 10 minutes, then infusion of 1g over 8 hours.

The primary outcome was death in hospital within 4 weeks (28 days) of injury. This was then broken down by cause of death:

• All cause mortality

• Bleeding

• Vascular occlusion (myocardial infarction, stroke, PE)

• Multiorgan failure

• Head injury

• Other

Primary outcomes were further stratified by time since injury, systolic BP, GCS, and type of injury in subgroup analysis.

Secondary outcomes included:

• Vascular occlusive events (myocardial infarction, stroke, PE, and DVT)

• Need for surgical intervention (neurosurgical, thoracic, abdominal, and pelvic)

• Receipt of blood transfusion

• Units of blood products transfused

• Level of disability (measured with the 5-point Modified Oxford Handicap Scale)

CRASH-2 Key Results:

A total of 10,060 patients were analyzed in the TXA group and 10,067 patients were analyzed in the placebo group. The primary outcomes are illustrated in the following table (Table 2 in Crash-2).

CRASH-2 Primary Outcomes

Essentially, there was:

• A decrease in any cause of death in TXA (14.5%) versus placebo (16.0%)

• A decrease in death by bleeding in TXA (4.9%) versus placebo (5.7%)

• No noted difference in deaths from multiorgan failure, head injury, or other causes.

To put this into perspective, the number needed to treat (NNT) is 68, meaning in order to save one life from any cause of death, you need to treat 68 patients with TXA. In order to save one life from death by bleeding, you need to treat 119 patients.

Importantly, in a secondary analysis of the data, they found that early administration reduced mortality even more!

• Within 1 hour: 5.3% (TXA) vs. 7.7% (placebo)

• Between 1-3 hours: 4.8% (TXA) vs. 6.1% (placebo)

As for the secondary outcomes, there was:

• No difference in vascular occlusive events

• No difference in need for transfusion or surgery

• Statistically significant increase in patients discharged with no symptoms in the TXA group

Now before we dive into the takeaways, let’s quickly talk about CRASH-3…

CRASH-3 Methods:

CRASH-3 likewise was a multicenter double-blinded, randomized, placebo-controlled trial involving 12,737 patients with the following inclusion criteria:

• Adults age ≥ 18 years

• Within 3 hours of injury

• No major extracranial bleeding

• GCS ≤ 12 or evidence of intracranial bleeding on CT scan

Likewise, primary outcome was death at 28 days, with secondary outcomes of complications, need for surgical intervention, disability, etc.

CRASH-3 Key Results:

CRASH-3 was able to show mortality benefit only in patients with mild to moderate head injury (GCS 9-15) with mortality of 5.8% in the TXA group versus 7.5% in the placebo group. To put it more practically, you would need to give 61 patients TXA with mild to moderate head injury in order to save 1 patient (NNT = 61). However, CRASH-3 was unfortunately not able to show a statistically significant reduction in mortality in all patient or a difference in disability. What is important, though, is that CRASH-3, like CRASH-2, was unable to show any increase in complications, therefore highlighting the safety of TXA.

Takeaways:

In these two incredibly large studies in a very heterogeneous population group, TXA has been shown to improve overall patient survival in trauma and, in a specific patient group, isolated head trauma. However, it’s important to remember that these improvements are modest at best. For all trauma, we are looking at a number needed to treat of 68 and for head trauma specifically, you are looking at a number needed to treat of 61, but only in mild to moderate head trauma.

So is it worth it? It probably depends! TXA in general is relatively inexpensive and very safe. Given that for our very sick trauma patients, there aren’t a lot of options other than to take them to the operating room faster or to drive the ambulance faster, it is incredibly reasonable to incorporate TXA into your practice.

Implications for EMS:

While trauma care in EMS has vastly improved in the United States, there is still room for improvement. As CRASH-2 and CRASH-3 have demonstrated, TXA is not only both efficacious and safe in trauma patients, but leads to even better outcomes when given as soon a possible after time of injury. As the first point of medical contact for our trauma patients, incorporation of TXA to EMS protocols can shorten the time to administration of TXA, especially in rural communities with long transport times, therefore improving patient survival.

Article Bites Summary by Alison Leung, MD (@alisonkyleung)

EMS MEd Editor: Alicia Buck, MD

EMS Physician Assistants: Are They the Next Paramedic Practitioner?

David Wright, PA-C, NRP & Bridgette Svancarek, MD, FAEMS

“There should be a paramedic to Physician Assistant (PA) fast track!”

“PAs and paramedics do about the same job!”

“Isn’t a PA doing the same job as a paramedic, just in the hospital?”

“Paramedics are just as good as nurses”

“Why don’t we [paramedics] get paid like nurses””

Over time, I’ve heard it all. The questions, the comparisons, the ideas of a fast track curriculum to ultimately go from Paramedic to Physician Assistant (PA). It seems a natural progression. Back in 1965, the first class of PA’s was established by a physician at Duke University. [10] The class was composed completely of Navy Corpsman with substantial medical training. This is the same place we get military medical training from today. Years later there have been many EMS professionals that have left EMS to go to PA school. Personally, as a paramedic who went to PA school, I can offer some insight in to this line of thought. Today it is difficult for some of our paramedics to make the transition. While paramedics are trained to be effective Emergency Prehospital Medical Providers, they are often not required to take the advanced sciences, such as Organic Chemistry, Biochemistry, Physics, statistics and psychology, among others. For paramedics to be able to transition to a PA, there needs to be additional training provided, in addition to PA school.

Let’s take a dive into the idea of having EMS PAs, who Dr Mark Escott (Medical Director of Austin Travis County EMS) has appropriately named, Paramedic Practitioners.

Current EMS Education

Today, EMS education is primary classified as a technical career. Most paramedic programs are required to be accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). CAAHEP accreditation is recommended by The Committee on Accreditation for the EMS Professions (CoAEMSP). CoAEMSP currently does not require a college degree as part of their minimum standards for accreditation. In 2013, the National Registry of Emergency Medical Technicians (NREMT) transitioned to a national standard of 4 separate types of emergency medical provider [2,3,13,14] :

Emergency Medical Responder (EMR) - EMRs complete approximately a 48-60 hour course that trains them to provide immediate life saving care to critically ill patients. They are trained to treat the immediate threat while awaiting additional EMS resources. They can perform basic interventions with minimal equipment.

Emergency Medical Technician (EMT) - EMTs complete approximately a 150-190 hour course that trains them to provide out of hospital emergency care and transport of the critical patients. They have basic skills and knowledge designed to stabilize and transport patients in both the emergency and non-emergent setting. They can perform interventions with basic equipment on an ambulance.

Advanced Emergency Medical Technician (AEMT)​ - AEMTs complete approximately 150-250 hour course that trains them to provide basic and limited advanced emergency care and transportation skills for the critical patients. They have additional training in comparison to EMTs and can perform basic and advanced interventions with both basic and advanced equipment normally on an ambulance.

Paramedic ​- Paramedics complete approximately a 1000 hour course that trains the allied health professional to provide advanced emergency care for critical patients. They have complex knowledge and skills to provide quality patient care and safe transport. They can perform both basic and advanced interventions and can utilize basic and advanced equipment found on an ambulance.

Specialty Paramedics are a relatively newer concept. They further specialize in specific types of care. In some states, there are certification courses and examinations that exist for specialties such as tactical medicine, community paramedicine, and critical care paramedicine. [3]​ There are no defined national standards regarding these specialty paramedics. While there may be a certification exam that is available, it may not be required to be obtained prior to practicing in that field. Without national standards, there is a lot of variation in the teaching and education of these types of providers. Some are short courses that could be offered in a weekend, while others are months or longer in duration.

Current PA Education

Table 1: Accreditation, Certification and Licensing Bodies for Paramedics and Physician Assistants.

Physician Assistant Education, on the other hand, is accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) and is typically a masters of science degree, with program length averaging 24-36 months. Currently most PA programs focus on general medical knowledge, such that pertains to primary care. [6] During the clinical portion of the program, multiple clinical rotations are complete in various specialties. These specialties include Emergency Medicine, Pediatrics, Obstetrics/Gynecology, Family Medicine, and Surgery. Many programs also allow for the student to have input in their clinical time and have a “student directed” clinical rotation, where the student can revisit a previously completed specialty, or experience something they have a personal interest in.

Once the professional program is completed, students are eligible to sit for the Physician Assistant National Certifying Exam (PANCE) exam. This exam is provided by the National Commission on Certification of Physician Assistants (NCCPA) who acts as the certifying body for PAs. NCCPA is to PAs what NREMT is for EMS professionals [Table 1].

Comparison to Nursing

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Table 2: Proposed comparison of nursing education to EMS education. Currently, in most states, paramedic is not currently an associates degree and there is no bachelor’s degree requirement.

Often our EMS profession is compared to the age old profession of nursing. While the concept of nursing has been around for a long time. The American Nurses Association was created in 1896, compared to the creation of EMS in 1966. [7,11] Today nursing has a hierarchy that can be compared to that in EMS, but EMS seems to comparatively fall short in education requirements. Nursing has placed value on formalized post secondary education. Nursing organization starts at Certified Nursing Assistant (CNA) and continues to Licensed Practical Nurse (LPN), Registered Nurse (RN), Bachelor of Science Nursing (BSN), Masters of Science:Nursing (MSN). This organization is very similar to EMS from EMR, EMT, AEMT, Paramedic and the proposed Paramedic Practitioner.

A proposed example comparing the Nursing education to EMS education is outlined in Table 2.

Proposed Educational Requirements

In 2018, the National Association of EMS Educators (NAEMSE), the National EMS Management Association (NAEMSE), and the International Association of Flight and Critical Care Paramedics (IAFCCP) released a joint position paper supporting the advancement of paramedics from a technician level program to a degree profession. [9] In 2013 NREMT changed the title of the Paramedic from EMT-P to Paramedic, in an effort to enhance the title by removing the technician label. [13]. In 2010, CoAEMSP recommended that all accredited paramedic programs be offered college credit of 30 credit hours. [12] This eases the transition from a technical program to degreed profession. Today there are many colleges/universities that currently offer Associate's Level degrees (usually Associate in Applied Science or Associate of Science) in Paramedic Care. According to the National Association of EMTs (NAEMT), there are currently only about 25 EMS four year degree programs or higher. [8]

Below is a proposed degree pathway for each of the level of EMS providers allowing smooth transition from paramedic to PA:

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Table 3: Proposal for future EMS Degree Pathway

Logistical Considerations for Requiring EMS Degrees

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Table 4: 2019 Salary Comparison between Nursing and EMS providers (All data sourced from Salary.com, average annual yearly salary)

Of the largest hurdles to requiring degrees for EMS education, time and money are at the forefront. NAEMSE has published a position paper stating on-line/distance education is one potential solution. [15] With the immersion of technology in the educational world, online programs are becoming more popular, and there are less challenges faced when moving these “additional courses” online. This would allow for them to be completed in a flexible, asynchronous manner, to anyone with a computer. This style of learning, would be able to accommodate the abnormal scheduling of many EMS providers.

Money is another limiting factor for EMS degrees. Many opportunities for assistance with finances for degrees are available, especially for those who currently do not hold a degree. Examples of such funding include Federal PELL grants, workplace assistant, community based scholarships, school based scholarships. Each one of these requires a small amount of work on behalf of the student, but there are many available opportunities for those willing to look for them.

When the salaries between nursing and EMS providers are compared [Table 4], it appears that in the technical programs (CNA vs EMT), our EMS providers are making 14% more than CNAs. An even smaller pay gap was identified with the Master’s Level providers (ED Nurse Practitioners vs the ED Physician Assistants) at 3%. Meanwhile the Associate’s Degree ED nurses compared to the technical program Paramedic had a significant pay gap with a 78% pay difference in the nursing favor.

Can an EMS Practitioner be a reality?

In short, YES! It is possible that today, an EMS Paramedic Practitioner be a reality, in fact, there are some systems utilizing PAs in EMS at this time. Yet, there are still some challenges before a well defined pathway may become available nationwide. Currently, many of these Paramedic Practitioners are former Paramedics who continued on with their schooling to become a Physician Assistant. A master’s degree PA with a Bachelor's degree in EMS can easily be the paramedic practitioner of the future. Another option is to customize a current PA program into having more of an EMS focus. Instead of having the aforementioned “student directed” clinical experience, this is then substituted for an EMS rotation. In place of the multiple rotations in family medicine, there would be greater emphasis on emergency and unplanned medicine.

Having this defined pathway may lead to viable, life long careers with advancement options for EMS providers. This could help combat the long standing feeling of the EMS profession having limited career progression.

It is likely to see more of these ideas emerging. With the implementation of programs like Emergency, Triage, Treat and Transport (ET3) model and alternative transport destination protocols, along with an increase in ED volumes, and increased wait times speciality care paramedics and paramedic practitioners are going to be playing a more critical role. As these programs grow and mature, there will be an increased need for these levels of EMS providers. Implementation of the above proposal can ease their transition into these roles.

There is no better time than now to reflect and decide in what direction we want our profession to head.

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References

1. Committee on Accreditation for the EMS Professions (2019) CAAHEP Standards & Guidelines. Accessed from: ​https://coaemsp.org/caahep-standards-and-guidelines#1

2. National Highway Traffic Safety Administration (2007) National EMS Care Content. Accessed from: https://www.ems.gov/pdf/education/EMS-Education-for-the-Future-A-Systems-Approach/ National_EMS_Core_Content.pdf

3. International Board of Specialty Certification (2020) Tactical Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/tactical-paramedic

4. International Board of Specialty Certification (2020) Community Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/community-paramedic

5. International Board of Specialty Certification (2020) Critical Care Paramedics. Accessed from: ​https://www.ibscertifications.org/roles/critical-care-paramedic

6. Physician Assistant Education Association (2013) Physician Assistant Educational Programs in the UInited States. Accessed from: https://paeaonline.org/wp-content/uploads/2016/10/27th-Annual-Report.pdf

7. American Nurses Association (2020) The History of the American Nurses Association. Accessed from: ​https://www.nursingworld.org/ana/about-ana/history/

8. National Association of Emergency Medical Technicians (2019) Degrees in EMS. Accessed from: ​https://www.naemt.org/about-ems/degrees-in-ems

9. 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

10. American Academy of Physician Assistants (2020). History of the PA Profession. Accessed from: ​https://www.aapa.org/about/history/

11. National Highway Traffic Safety Administration (1966) Accidental Death and Disability: The Neglected Disease of Modern Medicine. Accessed from: https://www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf

12. Committee on Accreditation for the EMS Professions (2010) Articulation Agreements: The Path to Offering College Credit for Your Accredited Paramedic Program. Accessed from: ​https://coaemsp.org/?mdocs-file=1368

13. National Registry of Emergency Medical Technicians (2013) Transition Policy. Accessed from: ​https://www.nremt.org/rwd/public/document/policy-transition

14. National Highway Traffic Safety Administration (2007) National EMS Scope of Practice Model. Accessed from: ​https://www.nhtsa.gov/people/injury/ems/EMSScope.pdf

15. National Association of EMS Educators, Position Paper on the Use of Internet Based Distance Learning in EMS Education., Pittsburgh, PA, 2003. Accessed from: https://cdn.ymaws.com/naemse.org/resource/resmgr/Docs/DLPositionPaper111003.pdf

(The Lack of) EMS Sleep and Wellness

by Andra Farcas, MD and Hashim Zaidi, MD

Is fatigue an expected work hazard for EMS providers? Based on experience from interacting with paramedics who make runs to the emergency department, it seems as if sleep on shift remains an uncommon occurrence. Many prehospital providers report getting little to no sleep in a 24 hour shift due to the high volume of calls in a busy urban EMS system and feel the consequences towards the end of the shift. Anecdotally, however, it seems as if they unanimously love the 24-hour shift structure and would only change the volume of runs they make in a shift. While subjective accounts are informative, we examined the literature to try to answer an important question: how does the lack of sleep and fatigue of a long shift affect EMS workers?

One of the most critical areas in which fatigue affects EMS workers is medical errors. One study found that fatigued EMS workers had 2.2 times greater odds of medical errors or adverse events compared to their non-fatigued colleagues, where fatigue was determined by self-reported surveys.[1]  This study also found that the number of shifts worked monthly was positively correlated to medical errors. Although performance is a difficult marker to measure in these types of studies, one surrogate marker has been psychomotor vigilance testing (PVT), which is a measure of behavioral alertness. One multisite cohort study performed PVT on EMS workers at the beginning and end of a shift and compared it by shift duration (24 hour shifts with shifts greater than 24 hours), as well as by time of shift. [2] They found no difference in PVT performance by shift duration but did find that performance was worse on night shift compared to day shift. They also found that performance increased as time from a nap to the test increased. For example, if prehospital personnel had napped in the hour before the test, they were more likely to do worse than if they had napped 3 hours before the test. The authors hypothesized this is likely due to sleep inertia, or grogginess upon waking. 

Another equally important topic to consider is EMS worker safety. Fatigued EMS workers have a 1.9 greater odds of injury and 3.6 greater odds of safety-compromising behavior compared to their non-fatigued colleagues, but the number of shifts worked per month and longer shift hours (24 vs <12hrs) are not associated with higher odds of negative safety outcomes. [1]  A longitudinal cohort study found that obese firefighters who didn’t get enough sleep on shift were twice as likely to report having had an on-duty injury in the past 6-12 months than those who felt like they received enough sleep. [3]  Interestingly, this was not significant in normal weight or even overweight firefighters.

Alongside worker safety, another area of importance that is often overlooked is EMS worker well-being. Occupational fatigue exhaustion recovery was found to be better for EMS workers who reported greater satisfaction with their schedule. [4]  Interestingly, recovery was reported to be worst for EMS workers on 12 hour shifts and better for those who worked longer than 12 hour shifts, which the authors hypothesize could be related to a longer turnaround time between shifts for EMS workers who work longer hours. EMS worker well-being should matter to everyone, since these workers are critical to the functioning of our health system. One study found burnout prevalence among US EMS workers was as high as 38% and that the presence of burnout is associated with a 2-3 fold increase in likelihood to leave a job or leave the EMS profession.[5]

The literature summarized above quantifies for us what we already qualitatively knew is a growing problem. While intervention trials and high-quality studies to examine improvements to this issue are sparse, there are potential areas of improvement to be noted in the literature.

Evidence- based guidelines suggest 5 items that can be used for fatigue risk management in EMS workers [6]:

1.     Decreasing shifts to less than 24 hours in length

2.     Monitoring and measuring fatigue

3.     Providing education and training about fatigue

4.     Encouraging napping

5.     Providing access to caffeine

The shift length question is certainly a highly contested one. Do 24 hour shifts need to be phased out? The existing evidence seems to point towards yes, but what is the ideal shift length? A systematic literature review found that shifts less than 24 hours in length are more favorable in terms of patient and personnel safety, although found that there was no difference the same outcome when considering 8 hour shifts vs 12 hour shifts.[7]  An observational study found the risk of occupational injury and illness was lower in shifts 8 hours or less compared to longer shifts; shifts that were 16-24 hours in length had 60% greater risk of injury compared to shifts 8-12 hours in length.[8]

While it may seem counterintuitive that more training about fatigue would help with fatigue management instead of adding to the workload of an already tired EMS worker population, there is data to back it up. One randomized control trial tested the utility of fatigue interventions at end of shift and 120 days post shift. [9]  Interventions were all done via text message and included recommendations in response to EMS worker self-rating their level of fatigue and quality of sleep. Recommendations were things like behavioral modifications to mitigate fatigue and weekly texts to encourage sleep. While the intervention group had no difference at 120 days from the control, they did have lower fatigue at the end of shift, indicating potential use in short-term fatigue management. Another study demonstrated that fatigue training in EMS workers was associated with improved patient and personal safety, lower ratings of acute fatigue, reduced stress and burnout, and improved sleep quality.[10]  This training consisted of basic information on sleep, circadian rhythms, and sleep disorders, as well as the use of caffeine or nap strategies, optimization of sleep schedules or sleep environment, and practicing increased mindfulness.

Another fairly manageable solution to improve on shift fatigue is structured napping. While napping may not drastically change reaction time, it is associated with decreased sleepiness at the end of shift. [11] Even though performance can be decreased soon after waking up from a nap [2], the evidence for the benefits of napping outweighs any detriments sleep inertia may cause. 

While napping may not be feasible for many busy EMS units, caffeine has been explored as a potential substitute.  One literature review found that in non-EMS shift workers, caffeine improved reaction time and PVT at the end of shift but with the caveat of, as expected, reducing sleep quality and duration. [12]  Shift fatigue continues to be a challenge for EMS shift workers but one potential solution may be sleep banking.  [13] This strategy involves extending sleep prior to scheduled shifts and may improve performance and acute fatigue.

Take Home Message

 The perceived benefits of shift work in emergency services have ensured it as a staffing model for decades to come in EMS and emergency medicine. The drawbacks, however, are prevalent and still not fully understood. Ensuring well rested and capable EMS workers will continue to be a challenge as long as shift work is preferred. More research is certainly needed and future robust studies looking at important topics such as shift length and on-shift interventions are essential. In the meantime, the literature suggests that while fatigue and sleepiness are real issues in EMS workers, some things that may help are education and training about fatigue, providing access to caffeine, and encouraging on shift napping if possible. While the shift length question remains contested, this is an informed discussion that needs to take place with EMS workers at the local level with the available understanding of the benefits and consequences of current staffing patterns.

 References:

1.     Patterson, P.D., Weaver, M.D., Frank, R.C., Warner, C.W., Martin-Gill, C., Guyette, F.X., … Hostler, D. (2012). Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehospital Emergency Care, 16(1), 86-97.

2.     Patterson, P.D., Weaver, M.D., Markosyan, M.A., Moore, C.G., Guyette, F.X., Doman, J.M. … Buysse, D.J. (2019). Impact of shift duration on alertness among air-medical emergency care clinician shift workers. American Journal of Internal Medicine, 62, 325-336. 

3.     Kaipust, C.M., Jahnke, S.A., Poston, S.C.W., Jitnarin, N., Haddock, C.K., Delclos, G.L., & Day, R.S. (2019). Sleep, Obesity, and Injury Among US Male Career Firefighters. Journal of Occupational and Environmental Medicine, 61(4), e150-e154.

4.     Patterson, P.D., Buysse, D.J., Weaver, M.D., Callaway, C.W., & Yealy. D.M. (2015). Recovery between Work Shifts among Emergency Medical Service Clinicians. Prehospital Emergency Care, 19(3), 365-375. 

5.     Crowe, R.P., Bower, J.K., Cash, R.E., Panchal, A.R., Rodriguez, S.A., Olivo-Marston, S.E. (2018). Association of Burnout with Workforce-Reducing Factors among EMS Professionals. Prehospital Emergency Care, 22(2), 229-236. 

6.     Patterson, P.D., Higgins, J.S., Van Dongen, H.P.A., Buysse, D.J., Thackery, R.W., Kupas, D.F., … Martin-Gill, C. (2018). Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. Prehospital Emergency Care, 15(22), 89-101.

7.     Patterson, P.D., Runyon, M.S., Higgins, J.S., Weaver, M.D., Teasley, E.M., Kroemer, A.J., … Martin-Gill, C. (2018). Shorter Versus Longer Shift Durations to Mitigate Fatigue and Fatigue-Related Risks in Emergency Medical Services Personnel and Related Shift Workers: A Systematic Review. Prehospital Emergency Care, 15(22), 28-36. 

8.     Weaver, M.D., Patterson, P.D., Fabio, A., Moore, C.G., Freiberg, M.S., & Songer, T.J. (2015). An observational study of shift length, crew familiarity, and occupational injury and illness in emergency medical service workers. Occupational and Environmental Medicine, 72(11), 798-804. 

9.     Patterson, P.D., Moore, C.G., Guyette, F.X., Doman, J.M., Weaver, M.D., Sequiera, D.J., … Buysse, D.J. (2019). Real-Time Fatigue Mitigation with Air-Medical Personnel: The SleepTrackTXT2 Randomized Trial. Prehospital Emergency Care, 23(4), 465-478. 

10.  Barger, L.K., Runyon, M.S., Renn, M.L., Moore, C.G., Weiss, P.M., Condle, J.P., … Patterson, P.D. (2018). Effect of Fatigue Training on Safety, Fatigue, and Sleep in Emergency Medical Services Personnel and Other Shift Workers: A Systematic Review and Meta-Analysis. Prehospital Emergency Care, 15(22), 58-68. 

11.  Martin-Gill, C., Barger, L.K., Moore, C.G., Higgins, S., Teasley, E.M., Weiss, P.M., … Patterson, P.D. (2018). Effects of Napping During Shift Work on Sleepiness and Performance in Emergency Medical Services Personnel and Similar Shift Workers: A Systematic Review and Meta-Analysis. Prehospital Emergency Care, 22, 47-57. 

12.  Temple, J.L., Hostler, D., Martin-Gill, C., Moore, C.G., Weiss, P.M., Sequiera, D.J., … Patterson, P.D. (2018). Systematic Review and Meta-analysis of the Effects of Caffeine in Fatigued Shift Workers: Implications for Emergency Medical Services Personnel. Prehospital Emergency Care, 22, 37-46. 

13.  Patterson, P.D., Ghen, J.D., Antoon, S.F., Martin-Gill, C., Guyette, F.X., Weiss, P.M., … Buysee, D.J. (2019). Does evidence support “banking/extending sleep” by shift workers to mitigate fatigue, and/or to improve health, safety, or performance? A systematic review. Sleep Health, 5(4), 359-369.  

Article Bites #15: Benzo before Blood Sugar: A Proposed Algorithm for Prehospital Management of Pediatric Seizures

Article: Remick K, Redgate C, Ostermayer D, Kaji AH, Gausche-hill M. Prehospital Glucose Testing for Children with Seizures: A Proposed Change in Management. Prehosp Emerg Care. 2017;21(2):216-221.

Background:

Hypoglycemia is an easily identifiable and quickly reversible cause of seizures in the pediatric patient population. Current recommendations highlight the importance of identifying hypoglycemia prior to initiation of anticonvulsant therapy in children with suspicion for seizures. However, these recommendations conflict with prior research that suggest that very few pediatric patients with seizures require treatment for hypoglycemia. The investigators of this study hypothesized that hypoglycemia is an uncommon cause of seizures in the prehospital setting and they sought to derive an evidence-based algorithm for the evaluation of pediatric seizures by prehospital providers.  Furthermore, the study creators hypothesized that repeat blood sugar testing in the ED was not indicated in patients who had return to baseline or normal mental status.

Methods:

This was a retrospective study, the investigators conducted a retrospective chart review for all consecutive pediatric patients (age 14 or less) with a prehospital complaint of seizure that presented to a busy county hospital and pediatric medical center in Los Angeles between January 2010 and January 2011. Information was collected regarding recorded age, sex, past medical history, GCS (mental status), prehospital glucose measurement, whether or not patient was seizing in the field, seizure duration, transport time, mental status on arrival, disposition and final diagnosis.

Key Results:

A total of 770 consecutive pediatric seizure patients were examined during the one year time period. The investigators presented the following important key findings:

·       521/770 (67%) of patients had a glucose recorded on chart review

·       84/770 (14%) were actively seizing on EMS arrival

·       4/770 (0.5%) of all patients were found to be hypoglycemic in the field (0.8% of patients with blood glucose reported)

·       There was no statistically significant difference between blood glucose levels obtained in the field as compared to those in the ED

·       Almost 80% of patients were discharged home from the ED

·       The most common diagnoses were simple and complex febrile seizures

Takeways:

Among pediatric patients with a chief complaint of seizure, hypoglycemia was an extremely rare occurrence. Routine universal blood glucose testing for pediatric patients with concern for seizure prior to administering a benzodiazepine or who had returned to normal mental status was not supported based on the findings of this study.  Furthermore, repeat blood glucose testing was not supported for patients who return to normal or baseline mental status.

What This Means for EMS:

Seizure is a common chief complaint encountered in the prehospital setting. While hypoglycemia has classically been taught to be an important cause of seizures, the results of this study suggest that hypoglycemia is not common in children who present with seizures or altered mental status. Furthermore, fingerstick blood glucose measurements can cause children to experience significant pain. The issue of universal fingerstick blood glucose measurements in patients who present with concern for seizure is also tied into false negative low glucose values which often require repeat testing in the emergency department contributing to increased length of stay. The investigators of this study postulate that routine blood glucose testing of all children in the prehospital setting who demonstrate normal or baseline mental status is not indicated. The detrimental effects of universal blood glucose testing extend beyond just pain and increased length of stay, but has also been linked to potentially delaying administration of antiepileptic medications in children with status epilepticus.

The investigators of the study formulated a new algorithm for prehospital management of the various classes of seizure patients: 1) patients actively seizing, 2) patients with GCS <15, 3) patients at baseline mental status.

Figure 1 from Remick et. al.

Article Bites Summary by Al Lulla, MD (@al_lulla)

Article Bites #14: To Tube or Not to Tube in Cardiac Arrest?

Article: Benger JR, Kirby K, Black S, et al. Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. JAMA. 2018;320(8):779-791.

Background: 

The benefit of advanced life support measures in the management of patients with out-of-hospital cardiac arrest (OHCA) is controversial. Endotracheal intubation has long been considered the mainstay of definitive airway control in patients with cardiac arrest, however, there is a growing body of evidence to suggest that alternative airway interventions such as the implementation of supraglottic devices (i.e. laryngeal mask airways) may be of value. This is likely due to the ease in which these devices can be placed, and requirement for less training to obtain proficiency compared to endotracheal intubation. Studies looking at head to head comparisons of endotracheal intubation versus the use of supraglottic devices in OHCA are lacking. The primary goal of this study was to compare the difference in modified Rankin Scale (mRS) scores at hospital discharge or 30 days after OHCA in patients who were randomized to endotracheal intubation versus supraglottic device to see if supraglottic devices were superior.

Methods:

Between June 2015 and August 2017, the investigators conducted a multicenter, cluster randomized clinical trial involving 4 different ambulance services in England. Paramedics were randomized to use endotracheal intubation or supraglottic airways. In order to be included in the study, patients were required to meet the following criteria: 1) known or believed age greater or equal to 18; 2) non-traumatic OHCA; 3) treated by paramedic involved in study who was either first or second paramedic on scene; 4) continued resuscitation by EMS personnel. Patients were excluded from the study if they were prisoners, previously involved in the trial, had been deemed to have inappropriate resuscitation, had an advanced airway that was placed by another healthcare professional prior to arrival of study paramedics and patients that were known to be involved in other randomized control trials. The primary outcome of mRS score at discharge or 30 days after cardiac arrest was divided into favorable outcome (mRS score 0-3) or poor outcome (mRS score 4-6).

Key Results:

A total of 9.296 patients were enrolled in the trial, of which 4,886 patients were randomized to supraglottic airway versus 4410 were randomized to endotracheal intubation.  The investigators presented the following important key findings:

·       Favorable neurologic outcome [ mRS score (0-3)] at 30 days or hospital discharge (whichever came first): 6.4% (311/4882) in the supraglottic airway group versus 6.8% (300/4407) in the endotracheal intubation group (adjusted risk difference -0.6%; 95% CI -1.6%-0.4%)

·       In the subgroup analysis of 7576 patients who received advanced airway management (not intention-to-treat), more patients in the supraglottic airway device group had a favorable neurologic outcome (3.9%) vs. the tracheal intubation group (2.6%); risk difference, 2.1%; 95% CI, 1.2 – 2.9%

·       Successful initial ventilation: 87.4% (4255/4868) in the supraglottic airway group versus 79.0% (3473/4397) in the endotracheal intubation group (adjusted risk difference 8.3%; 95%CI 6.3% to 10.2%).

·       Rates of aspiration and regurgitation were not found to be different between the groups

Takeways:

Among patients with OHCA, advanced airway management with a supraglottic device was not associated with a favorable neurological outcome at 30 days compared to endotracheal intubation.

What This Means for EMS:

While the results of this study clearly indicated that advanced airway management with a supraglottic device was not associated with improvement in patient centered outcomes (in this case, neurological function), these devices were still associated with more successful initial ventilation without an increase in secondary complications such as aspiration/regurgitation. Furthermore, given the ease of use, less number of attempts required to obtain proficiency from a standpoint of training, and widespread availability, supraglottic devices are feasible intervention to provide airway support for patients with OHCA. Unlike endotracheal intubation which can be challenging to perform in the field with active chest compressions, supraglottic devices are easier to use in terms of temporary airway management and allow for the focus to be shifted towards measures that improve outcomes including high quality CPR and early defibrillation.

Article Bites Summary by Al Lulla, @al_lulla, Article Bites Editor

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)

Article Bites #13: How Often Do They Get More Than One? Naloxone Redosing in the Age of the Opioid Epidemic

Klebacher R, Harris MI, Ariyaprakai N, et al. Incidence of Naloxone Redosing in the Age of the New Opioid Epidemic. Prehosp Emerg Care. 2017;21(6):682-687.

Background & Objectives:

The surging opioid epidemic has largely been combated with the use of intravenous and intramuscular naloxone administration. More recently, intranasal naloxone has been shown to be easily administered by not only EMS providers, but also law enforcement and family members to help reverse potentially fatal overdoses. Recently, mixed overdoses and ingestions with far more potent agents (such as carfentanyl) are on the rise, necessitating repeat naloxone dosing. The primary objective of this study was to determine the incidence of repeat naloxone administration for patients with suspected opioid overdose. The secondary endpoint was a more detailed descriptive and statistical analysis evaluating the precise characteristics associated with individuals who required repeat naloxone dosing.

Methods:

The investigators conducted a retrospective chart review of the electronic health record of the largest EMS service in New Jersey. Charts were searched for the presence of naloxone administration and other key words including “drug overdose”, “poisoning” and “unresponsive”. Charts were examined between April 2014 and June 2016. In order to be included in the study, patients had to be over the age of 17 years and administered an initial dose of 2mg of intranasal naloxone. Initial naloxone administration was performed by law enforcement or a BLS unit per New Jersey state regulations. Subsequent doses of naloxone were administered by ALS units.  Resolution or “response” to therapy was defined as GCS of 15. In addition, demographic data was extracted from each patient encounter. 

Key Results:

In total, 2,166 patients received naloxone for suspected opioid overdose during the study period) April 2014 to June 2016). The key results from the study were as follows:

• 1,971 of 2,166 (91%) of patients had reversal of overdose symptoms after a single dose of naloxone administered by law enforcement or BLS units 

• 195 of 2,166 patients (9%) required a second dose of naloxone by an ALS unit given failure to respond after the initial dose

• 53 of 2,166 patients (2.4%) required a third dose of naloxone by an ALS unit

• Patients who required a second dose of naloxone had a mean GCS of 5.3 (standard deviation of 3.7). The mean respiratory rate was 10.4 breaths per minute with a mean oxygen saturation of 86.8%. 

• Patients who required a third dose of naloxone had similar mean GCS scores (4.9) and oxygen saturations (86.4%). Two-thirds of the 53 patients who received a third dose of naloxone improved to a GCS of 15, suggesting that the remaining 1/3 patients may have had an alternative diagnosis for their altered mental status.

Takeaways:

• Among patients with suspected opioid overdose treated with intranasal naloxone by first responders or ALS units, 91% of patients had complete reversal of symptoms after a single dose of naloxone, with only 9% requiring repeat dosing.

• Naloxone is overall very effective at reversing symptoms of opioid overdose after a single dose

What this means for EMS:

With the rising incidence of mixed ingestions, more potent opioids such as carfentanyl, EMS providers are faced with more complexities in the management of opioid overdose. This study suggests that, in addition to basic support of ventilations, naloxone is still the mainstay of management in these patients, and highly effective at reversing overdose symptoms. Furthermore, this study suggests that in the majority of cases, first responders including law enforcement, and BLS units may be able to safely manage opioid overdose without the need for ALS units. This may improve resource utilization in EMS systems that are already stretched very thin. 

Article Summary by Al Lulla, MD (@al_lulla)

Article Bites #12: The Profile of Wounding in Civilian Public Mass Shooting Fatalities.

Article: Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86-92.

Background & Objectives:

Civilian mass shootings are unfortunately on the rise and afflict the lives of many individuals and their families. Given the rising incidence and severity of these events, there has been much in the way of public initiatives at improving morbidity and mortality in individuals who have been critically wounded. Much of the prior emphasis on management of these patients in the prehospital environment has focused on external hemorrhage control with widespread education on use of tourniquets. The strong focus on civilian management of exsanguinating extremity hemorrhage during mass shootings is largely based on the blast injury patterns identified during the US operations in Iraq and Afghanistan which suggest that between 52% and 64% of injuries in combat are to the extremities. Whether these lessons translate to civilian mass shootings is unclear. The overall purpose of this paper was to precisely identify the anatomic wounding pattern, fatal wounds and incidence of potentially survival wounds in civilian mass shooting incidents. 

Methods:

The investigators conducted a retrospective study evaluating autopsy reports performed by medical examiners or coroners in 12 different mass shooting events. The investigators utilized the term “mass shooting” as defined by the FBI to mean:

1. An incident occurring in a public space with 4 or more deaths (not including the shooter);

2. Gunmen who select victims at random

3. Violence without means to an end (i.e. not associated with robbery

Using reports made available by the New York Police Department and the FBI that provide detailed descriptions of civilian mass shootings dating back to 1966, the investigators identified 78 events that met the above definition for mass shooting events. 56 events that met the above definition had medical examiners or coroners that could be contacted. If the medical examiner or coroner was not listed or they could be not be contacted, the mass shooting event was eliminated from analysis. Request for official autopsy reports were sent to the respective examiners/coroners. Based on these reports, data was compiled regarding body site of wound, type of injury, probable site of fatal injury and whether wounds were potentially survivable. 

Key Results:

In total, based on responses from medical examiners, a total of 12 mass public shooting events were analyzed in the study. A total of 139 fatalities with 371 total wounds were examined by the investigators. The key results from the study were as follows:

• There was an average of 2.7 wounds associated within the group of fatalities

• The case fatality rate for civilian mass shootings was 44.6% (compared to approximately 10% during Operation Iraqi Freedom and Operation Enduring Freedom as reported in other studies). 

• 58% of all victims (with fatal and non-fatal wounds) had at least one wound to head or chest/upper back

• 20% (28/139) of all wounds were to the extremity, of which none were deemed to be fatal

• 77% of all fatal wounds were identified in the head or chest/upper back. 

• In total, only 9 of the 125 fatalities or roughly 7% (14 excluded given absence of autopsy data) were determined to be potentially survivable 

• The most common survivable injury was a wound to the chest (89% of all survivable injuries) without obvious evidence of vascular or cardiac injury

• There was 100% agreement between the reviewers of the study regarding potential survivability of injuries

Takeaways:

• Only 7% of victims in civilian mass shootings had a potentially survivable wound. No fatalities likely occurred secondary to exsanguination from extremity hemorrhage

• The majority of wounds in civilian mass shootings occur primarily in the head, chest/upper back compared to combat environments where the majority of wounds occur in the extremities. 

• The case fatality rate for civilian mass shootings compared to military data was much higher, and associated with lower number of potentially survivable injuries 

What this means for EMS:

While our nation faces a crisis with the issue of gun violence at the forefront of public discourse, regardless of what stance one may take on this issue, one thing remains abundantly clear: EMS providers are front and center when it comes to management of victims of mass shootings in the field. Historically, much of the focus on managing victims of mass shootings has been based on Tactical Combat Casualty Care (TCCC) guidelines based on the US military conflicts on the battlefields of Iraq and Afghanistan. These guidelines are largely predicated on the management of exsanguinating extremity hemorrhage with the use of tourniquets. This study despite all its limitations including retrospective design, missing data, and possibility of miscategorization of survivable and non survivable injuries, calls into question the applicability of these findings to the civilian arena where body armor is not worn. Based on the results of this study, EMS providers on the front lines who bravely care for victims of civilian mass shootings may encounter patients with wounding patterns that differ significantly compared to those seen in combat. While there is no question the importance of training and implementation of easy interventions such as tourniquets for the management of extremity hemorrhage, perhaps EMS providers must have a broader implementation of other treatment strategies that more accurately reflect the injury profile seen in civilian mass shootings, such as penetrating chest trauma. The authors of the present study carried out a more recent analysis looking at the victims of the Pulse nightclub shooting in Orlando, FL. The findings of this newer study which examined this single event (versus the 12 events in the examined in the present study) identified a disproportionately higher rate of individuals with extremity wounds (90% versus 20%). In this newer study, 4 patients were determined to have preventable death secondary to extremity hemorrhage (or in this case, junctional hemorrhage in the axilla). These patients who died did not have any evidence of tourniquet application, further emphasizing the point that despite the overall low incidence of death from extremity hemorrhage in mass shootings, it remains a quick and easy intervention that has the potential to save lives. The authors further concluded that in the Pulse nightclub shooting, similar to the 12 prior incidents, the majority of fatalities were again secondary to torso injuries highlighting the need for other interventions such as decompression of tension pneumothorax, basic airway management and management of hypothermia, which likely play a critical role in improving the dismal survival rates associated with civilian mass shootings. 

References:

1. Smith ER, Shapiro G, Sarani B. Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event. Prehosp Emerg Care. 2018;22(6):662-668. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29693490

Summary by Article Bites Editor, Al Lulla MD (@al_lulla)

BSI, Scene Safe: Debating the Personal Protective Equipment of Today

by Noah Tyler, EMT-P

Peer Review by Aurora Lybeck, MD

We’ve all seen the news stories and videos: Mass shootings, violent gang activity, and targeted assaults on first responders are on the rise.  Fortunately, bullet and stab resistant vests have been effectively protecting most of our law enforcement officers for years.

Today, we see EMS personnel wearing ballistic armor to every call.  But wait a minute… we’re medical people, not one of those proverbial sheepdogs who protect the flock.  Is this overkill for EMS?  Are we addressing a blatant disregard for scene safety with a quick fix instead of education?  Are “tactical paramedic” ambitions jousting towards Don Quixote’s windmills?  Aren’t most violent or weapons-related responses contained and controlled by law enforcement long before paramedics step foot on scene?  They are in Lubbock, Texas… we call it “staging” in the area.  So why are we wearing ballistic vests for body armor?

A little history: A few years ago, our hospital-based EMS recognized the increasing rate of violence within Lubbock and began considering options to protect our EMS personnel without impeding patient care.  Our agency acknowledged that just like in the rest of the country, there were shootings, stabbings, and mass casualty threats within our city of nearly a quarter of a million people.  That said, we also had a strong, dedicated police force to keep us safe and we worked well together. 

Now jump ahead to 2018 --- Our hospital purchased ballistic vests for every field EMT, paramedic, and supervisor within our service.  It was not a strategically-planned and targeted weapons attack that brought about this change in protection.  There was no conflict or concerns about police protection for our staff.  Instead, it was the enormous rise in synthetic cannabinoid and bath salt abuse from 2013-2017 and the subsequent rise in calls for excited delirium, where we were confronted with patients who could not even be controlled with our standard sedation drug, Midazolam (Versed).  Small foil packets of tainted grass and other dried vegetation - something innocently named “Scooby Snax”, “Breeze”, or “Mr. Happy Potpourri” - sold for just $5 at the local smoke shop were presenting risk of serious injury to not only patients, bystanders, law enforcement, but our EMS personnel as well. 

Intramuscular ketamine quickly became our medication of choice to protect and tame the patient, as law enforcement was not always deployed for our scene safety needs as these 9-1-1 calls may have come in as an unknown medical, vomiting, seizures, or check welfare.  We saw a need for ballistic vests to protect ourselves from the weapon threats usually involved in these patient encounters. 

With multiple raids on smoke shops, improved legislation on synthetic cannabinoid sale and prosecution, and targeted efforts by Lubbock police working with state and federal agencies, the synthetic epidemic finally tapered down.  But Lubbock’s population was increasing and as with any growing city in the US, the rate of violence was on the rise.  Two of our EMS stations were shot at in a single night – fortunately, no one was injured.

Improved dispatch algorithms for EMS and law enforcement evolved and police were responding to the suspected weapons calls and now more potentially-violent excited delirium patients.  2018 seemed safer, so again, do we really need all of that expensive body armor?

The ball was already rolling through the finances department and UMC approved the purchase of the armor.  Our EMS staff started wearing the lightweight ballistic vests for those just-in case encounters with a violent, armed patient or questionable scene.  While the past history of violent events led to body armor use, we soon discovered a previously-unrecognized benefit in our daily meat-n-potatoes type responses.

One of our frequent 9-1-1 requests is the “check welfare” call where a friend or family member has not heard from an elderly parent, college-age son, or friend with an extensive medical history in several days.  Most of these concerned callers are living in another city or state and can’t just drive and check on the individual.  Or, a home medical alarm company contacts EMS for an elderly person who has fallen and is unable to stand back up.  These encounters are usually not a safety threat and we prefer to preserve our law enforcement resources for more pressing needs. 

There is something unique about Texas though, and particularly in the western part of the state: It seems that just about every man, woman, and child owns a gun.  Yes, even in Texas, a child can legally own (but not purchase) a gun.  Most individuals are responsible gun owners, and it’s not uncommon to walk into a home and see a locked steel gun safe weighing hundreds of pounds sitting in a corner of the bedroom.  But, Texas paramedics and EMTs don’t suddenly run out of the house screaming, “scene safety!” --- in contrast, it usually spurs a conversation about the gun collection and an exchange on the latest wisdom about hunting rifles.  Having trouble with small talk for assessing decisional capability?  Start with a few words about the upcoming deer season or wild hogs tearing up the farm fields and you won’t have to say a word.  Your patient will do all of the talking.

So, going back to body armor: Are these hunters trying to kill our paramedics?  Absolutely not.  Instead, the ballistic vests find their value in the unexpected encounters.  For example, we responded to a “check welfare” call where the out-of-state son was concerned about his father with recently-diagnosed mild dementia.  His father is highly-functional and lives at home with occasional visits from friends and community health partners.  The son frequently calls his father to check up on him, but this time he did not answer the phone so the son called 9-1-1.  We arrived on scene and knocked on the door, which happened to be unlocked --- another west Texas behavior.

While entering the residence, we announced ourselves as EMS and heard no response, so we cautiously continued into the home.  As we entered the hallway, a frail elderly man was found frantically rolling his wheelchair down the hall.  His eyes were fixated on the doorway behind us and he wouldn’t respond to our questions.  He didn’t seem to understand our role or purpose and instead was intent on pushing past to the door behind us.  As I glanced behind me, I saw exactly what he was driving towards: A double-barreled shotgun resting on the door post.  He was exerting every effort towards getting his hands on that weapon because in his mind, two intruders were in his home and they were the threat. 

Dementia is a horrible disease.  His case was supposed to be mild, but when coupled with an acute urinary tract infection that altered his mental status, he was doing exactly as we should expect him to do.  He was protecting his life and his home, responding instinctively as any normal Texan would confronting a home invasion.  I was able to secure the weapon before he reached the doorway and eventually calmed him, but what if his hands got to it first?  What if shots were fired just as we entered the doorway earlier?

Another response involved a call for diabetic complications out in a more rural area of the county.  In this case, we arrived to find the front door wide open and obtunded patient sitting in the hallway.  His blood glucose level was 30 mg/dL, and while occasionally agitated, he didn’t appear to be an immediate threat.  Just your standard-issue hypoglycemia call near the “passed out” stage with a known diabetes history.  While administering the IV dextrose solution (D10W), I noticed that house was in disarray, in need of a lot of repair, and it looked like candy was scattered across the floor --- he must have been aware that his blood glucose was dropping but couldn’t fix it on his own soon enough.

My partner was looking for a medical history or medications list in the house, and he stepped out of the nearby bedroom saying, “You need to see this”.  We changed places and as I walked into the bedroom, I saw well over 80 bullet holes in the ceiling, walls, and furniture.  Handguns and rifles were strewn across the bed and floor.  I immediately requested law enforcement and as they arrived, the patient regained most of his mental status.  He was calm, confused about our presence, but then remembered: He knew his blood glucose was dropping and dropping fast.  Decades of his difficult-to-control diabetes also taught him that he’d soon lose his ability to make sound decisions and didn’t want to harm anyone.  He emptied his weapons, but by that time, his brain chose the most unconventional method. 

Guns and other weapons are not the only threat.  The human body is a formidable weapon in itself.  The ballistic vests have protected our personnel from injuries that previously were once accepted as “part of the job”.  Physicians, nurses, and emergency center staff know these risks and injuries well.  Hypoglycemia, stroke/brain injury, medication effects, or drug/alcohol abuse can turn an otherwise pleasant individual into a kicking, screaming, biting, fighting weapon of pain.  Trying to bathe a cat would be a breeze in comparison.  The ballistic vests perform remarkably well in blunting the kicks, fists, and even bites towards our core.  These are the potential injuries that can be most disabling for us on scene and risk our safety. 

I offer the experience and scenarios not to boast on “war stories” or to instill fear towards every patient encounter.  But as we’re taught in our EMS classes and usually soon forgotten, every response has a potential for violence – intentional or not.  Complacency can be fatal, but at times we also face situations where the risks will never be discovered until it’s too late. 

The individual decision to use body armor is a personal one.  Some of our personnel see it as important as donning gloves with every call.  Others bring their vests into the ambulance every shift as required by policy, but only wear them during known weapon-involved calls.  While every paramedic or EMT is entitled to their own decision to use or not use their vest, it must be an informed one.  Body armor’s role is more than protection from bullets and knives during a targeted attack.  It’s the everyday calls: The daily hypoglycemia response, substance abuse, brain injury, or even delirium from untreated acute illness. 

As experienced providers and mentors, we should instill a culture of safety that embraces the wisdom offered by author and speaker Simon Sinek: “Leadership is absolutely about inspiring action, but it is also about guarding against mis-action.”  The action is convincing decision makers that body armor investment for EMS personnel is necessary, while mis-action leads us to assume it’s only valuable for known weapon calls.  Consider alternative scenarios to protect yourself and your partner from preventable, disabling injury that in just a moment of time, could destroy your career and livelihood if not life itself.

Response & Commentary

Mark Philippy, EMT-P

I read with great interest the article regarding the wearing of ballistic and protective vests in EMS.  This is something of a timely topic, as one of the committees I serve on in New York has this on our agenda as an item of discussion.  We have wrangled with the notion of creating a best practices document to help EMS agencies in our state address the need for, and deployment of, ballistic vests.  Some areas of the state have been able to move ahead in various ways to provide partial deployment, mostly of threat-level four plate-carrying vests for tactical environments, but few have delved, officially, into daily-wear vest systems.

First, I’d like to be transparent about some of my own biases and experiences. 

Among the proudest and happiest days in my life were the first day I put a bullet-resistant vest on – my first day out of the police academy, and the last day I took it off – the day I retired from police work.  For 23 years I wore the vest religiously, even though, at the time I started in 1990, it was not required for daily wear as a police officer.  There were those in my department who resisted mandatory vest wear, despite the fact that they carried a firearm into every single encounter they ever had with a citizen – a weapon that could potentially be turned against them.  Yet by the time I left, it was not even a second thought – the vest went on before the uniform.

Having said that, I hated it, too.  It was hot, bulky, stiff, and any time I got into any kind of tussle, I spent a good 20 minutes trying to get it seated right and getting my uniform tucked back in (I’m a bit challenged in that regard, I admit).  When agencies such as the Chicago Police Department first started testing the outside vest carriers that looked like uniform shirts, I cheered, hoping it would someday make it to my department (it didn’t, at least not before I retired).  I worked bicycle patrol for a number of years and I lost more weight from sweating than I did from the exercise.

Now look at the EMS side of things.  In the time that I worked in the City of Rochester, my ambulance had been shot at twice, I had been punched, kicked, bit, and threatened with stabbing, all the while (stupidly, I agree) walking right in with the local police on things that today, we’d stage down the block for until cleared into the scene.  At the same time, I scoffed at those medics who wore bullet-resistant vests.  Why?  Because it was my observation that those who did, immediately seemed to get into more trouble than they had before.  Likewise, it seemed the people who got into trouble were the first ones to put a vest on. 

By trouble, I mean those few (and we all know them) who managed to rile up every patient with a mental health issue, seemed to draw crowds around themselves at inopportune times, and got more than their fair-share of personnel complaints.  These were often the folks whose chest seemed to puff out a little too much, and who seemed to feel they could take on the world single-handedly.  I worried for them, and about their partners, all the time.

Fast-forward to 2019.  I cannot agree more with the author that things are violent and dangerous.  I don’t know that I would agree they are any more so than 30 years ago, when crack cocaine was rearing its ugly head, and excited delirium was still called “cocaine psychosis.”  But we are more aware, and we are busier, and so are our law enforcement partners.  So the danger may be more visible, in-your-face, not to mention we may be much more aware of it through social media and information sharing.  So where is my concern?

First of all, what is the purpose of wearing ballistic or edged-weapon protection?  I’m loath to bring up what events transpired in my region some not-so-distant years ago (particularly since it involved a friend and colleague), but in that instance, ballistic vests would not have been of benefit.  Yet immediately after that incident, fire departments around the region and the country started talking about buying ballistic vests.  My question then as now is, why?  When will you wear them?  Will you put them on under your turnout gear?  Will you wear them on every call all the time?  If you’re a career firefighter or EMS provider will you wear it all the time, over or under your uniform?

What does that mean for you, and for your practice?  Because I see a good number of people (and police officers now, which irritates me to no end) wearing outside-carry vests festooned with pockets and carry points.  So the uniform is no longer the first thing a patient sees.  It’s the ballistic vest.  We might no longer present the image of primary caregivers, but perhaps be easily mistaken for police.  They are bulky, catch on things, and yes, you can take them off, but they still get hot when they’re on, which for practical purposes, should be most of the time.

Let’s talk about under-uniform vests then.  For threat-level II or III (and their progeny, IIA and IIIA) vests, under the uniform wear makes sense.  It is less intrusive, less visible, and depending on what style is purchased, can be integrated with stab-resistance and water repellency.  They are also hot, stiff, and make movement about inside an ambulance, or incident scene, challenging.  Uniforms will be untucked and it will be annoying, but you can work through that.  The thing to watch out for is the feeling of increased protection morphing into a sense of improved invulnerability.  And thence, potentially, increased risk-taking.

What else?  Cost.  Who bears the brunt of that?  The author was fortunate to have a hospital system than was progressive and financially positioned to purchase these, but what about municipal, commercial, not-for-profit, and volunteer agencies?  Medicare reimbursements being what they are, we are all holding on by a thread just to upgrade aging cardiac monitors and keep ambulances running.  While taking care of our people should be foremost in company leadership’s mind, does that extend to providing this level of protection?

In the law enforcement world, the National Institutes for Justice realized early on that the benefit of protective bullet-resistant vests warranted federal subsidy.  For every year that I was on the job, my vest was partially, and in some cases wholly, funded through federal grants.  Are those same grants or funding streams available for fire and EMS personnel?

The author points out that it is important for people to make informed decisions about wearing vests.  So let’s talk about some limitations and considerations.  If you have to buy a vest, I return to the question of what threat level?  What are you protecting against?  Small arms, rifles, close range, far away?  Of much more concern to me is, frankly, edged weapons.  However most bullet-resistant vests do not protect adequately from stabbing, thus Corrections’ use of SpectraTM and similar materials in stab-resistant vests.  There are those manufacturers who incorporate both (I had one for Bike Patrol) but they are increasingly expensive.  So cost and type of protection are key factors in this decision.  And I submit few EMS providers, let alone agency leaders, are knowledgeable enough to make these choices, so if you are considering it, best do your research or find yourself a subject matter expert to help.

What about moisture?  KevlarTM and TwaronTM fabrics, which make up the bulk of bullet-resistant vest manufacture, are susceptible to becoming soaked through, at which point they lose some or most of their ballistic integrity.  This was one reason I chose to use a combined Spectra/Twaron vest for bike patrol.  EMS providers are often in the rain, and sweating in cramped, semi-conditioned environments, so how effective will your protection be when the time comes?  As a police officer, I had the luxury of being able to go back to my station and swap carriers, keeping my car air conditioned, and making darn sure I wore a raincoat when I was outside for a period of time (most of the time, anyway).  That has not always been the case as an EMS provider.

What about training for the intended user?  How much training do EMS providers have in the limitations, care, and replacement of bullet-resistant vests?  I was acutely aware of the fact that I had a huge open area under my armpits that was not protected.  It was never so apparent as when I wore a short-sleeve shirt in changing weather, and could feel the cold air rush up my arm while in a standard bladed stance addressing a potential adversary.  Do EMS providers know how to stand to maximize their ballistic protection?  Do they know how far down the vest goes, or doesn’t go, to protect their abdomen, and their sides?

Up to this point I’ve somewhat danced around the issues of why we should wear the vest, and written about the challenges and considerations.  I don’t think anyone can argue, with any kind of standing, that there is not a place for bullet-resistant and edge-weapon protective vests in the EMS environment.  I do believe that there are a good number of considerations that must be addressed before anyone lays a hand on one, or picks up the thread to start obtaining them.  The author makes excellent and valid points about the ancillary protective benefits of the vests, from blunt attacks to motor vehicle crashes.  I know of a friend who avoided a serious spinal injury during a crash because his ballistic vest acted much like a KED.  But when we talk about “lightweight ballistic vests,” let’s make sure we’re talking apples and apples, and not Kevlar and Spectra.

Finally, I agree with the author that there is a particular lack of situational awareness (Oh, how I hate that term!) in EMS today.  It is getting better, and there are a number of good programs across the country trying to improve not only provider safety awareness, but EMS defensive tactics (shout out to Kip Teitsort and the folks at DT4EMS).  I posit that we should be spending our hard-won funds in this area before we invest in protective vests.  Then, and only then, can we fully understand the threat, and address the use of protective equipment effectively.

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

Trouble in Thin Air: Responding to Inflight Medical Emergencies

By Mark Liao, MD, NRP (@EMSFellowMark)

Peer Reviewed by Jeremiah Escajeda, MD (@JerEscajeda)

Clinical Scenario:

As you settle into your seat on a cross-country airline flight to yet another Emergency Medicine conference, you hear the familiar Hi-Low tone signaling an announcement. Suddenly a pressured, yet professional, voice booms overhead: “If there is a medical professional on board the aircraft, would you please contact a member of the cabin crew?”  You pause for a moment and do a mental size up – what exactly would I be able to provide? Am I protected legally? What equipment is on board? The uncomfortable realization that you may be on your own – at 35,000 feet – quickly settles in as you unbuckle your seat belt and walk to the nearby galley.

Review:

Legacy Emergency Medical Kit prior to the 1998 Aviation Medical Assistance Act

Medical professionals such as EMS providers and physicians have always been aware that they may be called upon to respond as Good Samaritans in the event of an off-duty emergency. Aviation in-flight medical emergencies are uncommon events, with estimates ranging widely from 1 event every 40 flights to 604 flights or up to 10-40 events every 100,000 passengers [1-3]. The variation in estimates are due to the lack of a central registry with most studies relying on proprietary company data from either the airlines or a ground-based aeromedical consultation service.  Common in-flight medical events include syncope/near-syncope, GI complaints, respiratory problems and cardiovascular emergencies. Cardiac arrest is rare, with one review showing it represented only 0.3% of all inflight medical events [4].

Fortunately for potential first responders, the United States 1998 Aviation Medical Assistance Act provides generous legal protections for American air carriers:

Current emergency Medical Kit that meets minimum FAA Part 121 EMK requirements

An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct [5].

 The same law also updated required equipment on board commercial civil aviation aircraft in the United States. A scheduled air carrier – which the FAA calls a Part 121 Operator – is what most passengers fly in the United States. If a Part 121 aircraft has at least one flight attendant on board, the aircraft is required to have an Emergency Medical Kit (EMK), Automated External Defibrillator (AED), general first aid kit, bloodborne pathogen spill equipment and oxygen for first aid (if the aircraft operates above 10,000 feet) [6]. All Part 121 cabin crew in the United States are required to receive first aid and CPR/AED training, with demonstration of CPR/AED skills every 2 years, in addition to being familiar with the location of equipment on board the aircraft [7]. However, cabin crew education on obtaining vital signs or performing a physical exam is not required by regulations.   

Preparing to Respond

Above: An example of an in-flight patient care form

Each airline dictates their own policy on identifying potential medical volunteers and may request professional identification. Some international airlines – such as Japan Airlines, Lufthansa, SWISS and Austrian Airlines – maintain a registry of physician passengers who can be called on to render assistance if needed [8,9]. Medical volunteers, such as physicians who choose to respond should not have consumed alcohol prior to rendering care or otherwise be impaired [10]. Many airlines across the globe are contracted with an aeromedical ground support service, such as MedLink (located in Arizona) or Stat-MD (located in Pennsylvania) that provides physician consultation and helps the flight crew determine if diversion is necessary and assists cabin crew and volunteers with passenger medical care. They also perform ground based medical evaluations of patients if there is a concern that arises as to whether the patient is medically suitable to fly on a commercial flight. The ultimate decision for diversion rests with the pilot-in-command who will use the ground-based physician service and possibly inflight medical volunteers to assist in making the decision. Diversion is very costly and airlines attempt to avoid medically unnecessary diversions. Given the unique considerations of the aeromedical setting, suitable airports and local available services, medical volunteers should defer to the recommendations of the ground physician. Communication with the ground physician may take place with in-cabin headsets, telemedicine equipment or relayed through the flight deck.  Some airlines – particularly those flying long-haul routes – have also elected to equip their aircraft with patient monitors that integrate voice communication, video, EKG, pulse oximetry, temperature and other parameters that can be transmitted to the ground physician, though these are rare to find on domestic US operations [11]. Airlines will ask that volunteer help complete documentation for care that is rendered.

Vital Signs

The only FAA required vital signs equipment in an EMK is a stethoscope and blood pressure cuff. Auscultation of breath sounds and blood pressure can be challenging due to engine noise and vibration. As such, blood pressures may need to be palpated. Pulse oximeters, while not required by regulations, are sometimes added to EMKs, although providers should be aware that the effects of altitude may cause normal changes in oxygen saturation. While oxygen saturation at sea level is approximately 97%, decreased oxygen tension at altitude will reduce this saturation value. Most civilian airlines are pressurized to maintain a cabin altitude of approximately of 6,000 to 8,000 feet: at 8,000 feet a normal oxygen saturation will be approximately 93% [12]. 

IV and Medication Administration

The EMK is required to stock a limited amount of parental medication equipment and includes one IV tubing set with Y-connectors, 500cc of normal saline, 5cc and 10 cc syringes in addition to medication needles. As many EMKs utilize vial or ampoule epinephrine instead of an epinephrine autoinjector, 1cc syringes are also included. Curiously, the FAA did not specify the type or quantity of intravenous catheters to be equipped, thus leaving the decision up to the airlines or their EMK vendor. The author has seen as few as two 16-gauge IV catheters to a more generous set of one 18, 20 and 22 gauge IV catheters.

Airway and Ventilation Support

 Basic airway adjuncts are included in the kit and at a minimum must include a bag-valve resuscitator (regulations do not specify what size), 3 sizes of oral airways and masks (pediatric, small adult, large adult) and CPR masks of equivalent sizes. The EMK presented above met these requirements by providing three mask sizes that could be either used with the adult bag mask resuscitator or a one-way CPR valve. Oddly, there is no requirement for the equipped bag-valve resuscitator to have oxygen tubing that is compatible with the aircraft portable oxygen bottle outlets.

Portable aircraft oxygen bottles, unlike those found in medical settings, are generally equipped with only two settings, low (2 liters per minute) and high (4 liters per minute). For these types of bottles, applying the mask adapter into the appropriate rate connection outlet will determine the flow rate.

A bronchodilator is also required as part of the EMK. A spacer, which is not required to be equipped, may need to be improvised using a toilet paper roll, rolled-up magazine or plastic bottle when treating children [13].

Syncope

Based on previous literature, near-syncope and syncope comprise the majority of inflight medical emergencies. This condition, although frightening to the crew and other passengers, rarely requires IV administration or diversion. Simple maneuvers such as laying the patient supine, with legs elevated and applying oxygen, for the most part, are all that is required [2,4].

 Nausea/Vomiting

 Antiemetics are not required to be equipped in the EMK despite nausea and vomiting being a common inflight medical event. Although carrying antiemetics while traveling is advisable, it should be noted that serotonin receptor antagonists, such as ondansetron, are not effective for motion sickness [14]. Alternatively, the EMK does carry diphenhydramine which can be used off-label as an antiemetic. It is also reasonable to request if other passengers may be carrying over the counter antiemetic medications. 

 Cardiac Emergencies

The EMK provides four 325mg of aspirin and at least 10 tablets of nitroglycerin. There is no requirement to include a single or 3-lead EKG as part of the equipment, though some airlines include this as a stand-alone device or optional attachment to the on-board AED [15].

Cardiac Arrest and Resuscitation Management

In addition to the on-board Automated External Defibrillator, the EMK provides two doses each of 1mg atropine and 1mg epinephrine. A total of 200 mg of lidocaine is also required. Despite the provision of antiarrhythmics, there is no requirement for airlines to ensure that the equipped AED has a screen that permits the user to see the underlying cardiac rhythm.  Due to space constraints within the cabin, patients in cardiac arrest may need to be moved or dragged to the galley or a bulkhead row to ensure enough space is provided to render effective CPR. Ending resuscitation can be challenging and consultation with the ground physician is advisable.

 Allergic Reactions and Anaphylaxis

 Diphenhydramine in both oral and injectable forms are provided in the EMK, with four 25mg tablets and two 50mg vials.  Two ampoules of epinephrine 1mg/mL (1:1000) must also be equipped. Some airlines have included epinephrine autoinjectors as part of their EMKs, but this is not required by regulations.

Diabetic Emergencies

A total of 25 grams of injectable dextrose is equipped in the EMK, though there is no requirement for a glucometer or lancets. If a glucometer is needed, one option is to ask the cabin crew to make a public address announcement to see if another passenger may be willing to volunteer a personal one. An alternative is to assume the blood sugar is low (particularly in a syncopal event) and to provide an oral dextrose source such as orange juice if the passenger is able to drink.

 Upcoming Developments

 The EMK was primarily designed for adult medical emergencies and lacks pediatric appropriate supplies and equipment. In 2018, the FAA Reauthorization Bill was passed which included verbiage from the Airplane Kids in Transit Safety Act and directed the FAA to revise the EMK to meet the needs of children [16]. The FAA has yet to provide guidance in response to this bill.

 International Regulations and Equipment

Figure 14

An EMK that meets European AMC1 CAT.IDE.A.225 regulatory requirements

Internationally, wide variations exist for on-board medical equipment. In Canada, an AED is not required by regulations and an EMK is only required on civil aircraft carrying more than 100 passengers [17, 18].  In Europe, defibrillators are not required, although are recommended if an aircraft has 30 or more passengers with at least one member of cabin crew [19].  One 2014 paper found that many German airlines did not carry AEDs and one carrier did not have any CPR equipment on board [20]. In contrast, some airlines on their own initiative, such as British Airways, far exceed these requirements, carrying an extensive array of medications and equipment including benzodiazepines, buprenorphine, antibiotics and suture equipment [21]. These optional enhancements have led to several remarkable stories of innovation and improvisation, including a 1995 case in which a physician volunteer improvised a chest tube for a passenger suffering from a tension pneumothorax using a urinary catheter found in the British Airways medical kit [22].

 Conclusion

 Despite the perceived austere clinical environment a commercial aircraft might present, US airline carriers are equipped with emergency medical supplies that a physician volunteer can effectively utilize. Whenever possible, the medical volunteer should consult with ground based medical support.  Familiarity with what and what is not carried will enhance a volunteer provider’s ability to respond to in-flight emergencies. For further information, an excellent review in JAMA is published at https://jamanetwork.com/journals/jama/article-abstract/2719313

References

[1] Epstein, Catherine R, et al. “Frequency and Clinical Spectrum of in-Flight Medical Incidents during Domestic and International Flights.” Anaesthesia and Intensive Care, vol. 47, no. 1, 13 Feb. 2019, pp. 16–22., doi:10.1177/0310057x18811748.

[2] Peterson, D. C., Martin-Gill, et al.  (2013). Outcomes of Medical Emergencies on Commercial Airline Flights. New England Journal of Medicine, 368(22), 2075-2083. doi:10.1056/nejmoa1212052

[3] Kesapli, Mustafa, et al. “Inflight Emergencies During Eurasian Flights.” Journal of Travel Medicine, vol. 22, no. 6, 2015, pp. 361–367., doi:10.1111/jtm.12230.

[4] Martin-Gill, C., Doyle, T. J., & Yealy, D. M. (2018). In-flight medical emergencies. JAMA, 320(24), 2580-2590. doi:10.1001/jama.2018.19842

[5] U.S. G.P.O. Public Law 105 - 170 - Aviation Medical Assistance Act of 1998 (1998) (enacted).

[6] FAA. (2006). Emergency medical equipment (121-33B). Retrieved from

https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-33B.pdf

[7] FAA. (2006). Emergency medical equipment training (121-34B). Retrieved from https://www.faa.gov/documentLibrary/media/Advisory_Circular/AC121-34B.pdf

[8] JAL. (n.d.). JAL DOCTOR Registration System. Retrieved from https://www.jal.co.jp/en/jmb/doctor/

[9] Lufthansa. (n.d.). Doctor on Board. Retrieved from https://www.lufthansa.com/de/en/doctor-on-board

[10] Nable, J. V., Tupe, C. L., Gehle, B. D., & Brady, W. J. (2015). In-Flight Medical Emergencies during Commercial Travel. New England Journal of Medicine, 373(10), 939-945. doi:10.1056/nejmra1409213

[11] Doyle, A. (2010, December 7). MEBA: RDT demonstrates Tempus IC telemedicine system. Retrieved from https://www.flightglobal.com/news/articles/meba-rdt-demonstrates-tempus-ic-telemedicine-system-350616/

[12] Gradwell, D., & Rainford, D. (2016). Hypoxia and hyperventilation. In Ernsting's Aviation and Space Medicine 5E (pp. 55-56). Boca Raton, FL: CRC Press.

[13] Zar, H. (2000). Are spacers made from sealed cold-drink bottles as effective as conventional spacers? Western Journal of Medicine, 173(4), 253-253. doi:10.1136/ewjm.173.4.253

[14] Gradwell, D., & Rainford, D. (2016).Motion Sickness. In Ernsting's Aviation and Space Medicine 5E (pp. 794-795). Boca Raton, FL: CRC Press.

[15] JAL. (n.d.). Medical Supplies and Equipment on Board. Retrieved from https://www.jal.co.jp/en/health/medicines/

[16] Kraft, C. (2018, October 3). AAP Applauds Passage of Bill That Will Keep Children Safe During Air Travel. Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAPStatementAirplaneKiTSAct.aspx

[17] Transport Canada. (2018, April 5). Advisory Circular (AC) No. 705-010. Retrieved from http://www.tc.gc.ca/en/services/aviation/reference-centre/advisory-circulars/ac-705-010.html

[18] Transport Canada. (2019, March 18). Part VII - Commercial Air Services. Retrieved from https://www.tc.gc.ca/eng/civilaviation/regserv/cars/part7-standards-725-2173.htm#725_90

[19] EASA. (2018). Carriage and use of Automatic External Defibrillators (2018-03). Retrieved from https://ad.easa.europa.eu/blob/EASA_SIB_2018_03.pdf/SIB_2018-03_1

[20] Hinkelbein, J., Neuhaus, C., Wetsch, W. A., Spelten, O., Picker, S., Böttiger, B. W., & Gathof, B. S. (2014). Emergency Medical Equipment On Board German Airliners. Journal of Travel Medicine, 21(5), 318-323. doi:10.1111/jtm.12138

[21] British Airways. (n.d.). BA Medical Kit. Retrieved from https://www.britishairways.com/health/docs/during/Aircraft_Medical_Kit.pdf

[22] Wallace, W. A. (1995). Managing in flight emergencies. BMJ, 311(7001), 374-375. doi:10.1136/bmj.311.7001.374

Article Bites #11: Measuring the Impact of a Telehealth Program on Ambulance Transports

Article Reviewed:

Champagne-langabeer T, Langabeer JR, Roberts KE, et al. Telehealth Impact on Primary Care Related Ambulance Transports. Prehosp Emerg Care. 2019;:1-6. [PMID: 30626250]

Background & Objectives:

Prior studies have confirmed what is known by many of those who work in EMS: a high proportion of patients that are transported have non-emergent conditions. Several studies have demonstrated that between 33 and 50% of all ambulance transports are for non-emergent causes. These transports often times result in signifiant resource utilization from EMS systems that are stretched very thin.  Furthermore, these transports may often be linked with ED overcrowding problems and increased healthcare costs. The role of telehealth has already been shown to be a cost effective and beneficial approach to many aspects of healthcare, including tele-ICUs and within EMS as part of trauma, stroke and cardiovascular care. The primary objective of this study was to investigate the impact of a large-scale telehealth program that utilizes non-ambulance based transportation (i.e. taxi) and paramedic triage of non-urgent complaints on overall EMS transports.

Methods:

The investigators conducted an observational study from January 2015 to December 2017 for patients triaged by the Emergency Telehealth and Navigation Program (ETHAN) program developed by the Houston Fire Department. According to the study protocol, EMTs and paramedics were tasked with enrolling patients with non-life threatening conditions or mild illnesses. To be formally included in the study, the following criteria needed to be met:

1. full history and physical exam with no obvious emergency

2. age >3 months

3. English speaking

4. Normal vital signs; afebrile if chronically ill or over 65 years of age

5. ability to care for self

6. ability to be transported in a passenger vehicle. 

Patients who did not meet all inclusion criteria or who had other high risk features of their presentation suggestive of an emergency condition were excluded from the analysis. For those who qualified for the study, enrollees were connected via tablet to a board certified emergency physician who determined if the patient could be referred for follow-up with a primary care facility via versus requiring transport via ambulance. The primary variable that was studied was whether patients were transported by ambulance. Patients who were not transported via ambulance were offered transport to the ED or a primary care facility via taxi. 

Key Results:

During the study period, the investigators enrolled 15,067 patients in the telehealth program (equivalent to 2% of the overall EMS volume during this period). The key results from the study were as follows:

• 11.2% of patients in the telehealth program were transported by ambulance

• 75.6% of patients were transported by taxi instead of ambulance (5% of these patients were transported to a clinic instead of the ED)

• 13.2% of patients transported themselves or were not transported at all

• Patients were more likely to be transported by ambulance in the telehealth program if the chief complaint was abdominal pain (19.6%), low-risk chest pain (8.3%), shortness of breath (5.2%), or dizziness (3.7%)

Takeaways:

• Over the course of the study period, a telehealth program to identify patients with non-emergent conditions was successful in helping avoid unnecessary ambulance transports

What this means for EMS:

EMS agencies are faced with increased demand of services by the public with decreased available resources and higher costs. Telehealth in the prehospital setting is a novel approach to identify patients that may be suitable for transport via taxi and allow for EMS units to stay in service and serve other patients who present with other time critical conditions. This study did not show a significant decrease in the number of patients that were ultimately transported to the ED (only 2% of overall call volume participated & the majority of patients were still transported to the ED via taxi) and did not provide patient outcome data regarding accuracy of triage as non-emergent. However, it does demonstrate that a telehealth program is feasible within a large EMS system and highlights a promising avenue towards matching healthcare resources with patient needs and thus represents an important advancement in the field of EMS medicine.

Article Review by EMS MEd Article Bites Editor, Al Lulla MD (@al_lulla)

ET3: Perspectives of a Paramedic and PA

As both a Paramedic and an Emergency Medicine Physician Assistant I commend those who made the announcement of the Emergency Triage, Treat and Transport (ET3) payment model a possibility.  This is by far, one of the biggest steps in the advancement of modern EMS.  This historic payment model could finally bring an end to the “you call, we haul” motto that has plagued EMS since its inception.  One of the most beneficial sections of this new payment model is that it allows current EMS providers the option to transport to hospitals, urgent cares, primary care offices, or, when necessary, to “stay and play”, allowing EMS professionals to provide treatment in place with qualified healthcare providers, via telehealth when necessary.  While I feel this is beneficial to the EMS community as a whole, it begs the question what does this mean for the day to day provider?

As a paramedic, I am thrilled that this may curve the overwhelming amount of calls that do not require trips to the emergency room.  I can recall many trips for simple requests, such as  prescription refills, cast removal, cold and cough symptoms, or suture removal that would be placed in triage and often still be sitting in the same seat when I returned with the next patient.   I often thought to myself that there has to be another way - that trips to the ED were not always the answer, but if only we could take them to their primary care office, or utilize technology to communicate with their provider.  Then there were the many calls I would run that would end without any transport at all.  Often there would be treatment provided on scene, but then would come the refusal of transport.  For paramedics, these are also some of the highest risk refusals, but that’s another topic on good documentation.  I feel that the lack of access to healthcare was the basis of many non-transport calls, people whose only reliable way to see a provider was to call 911.  A perfect example is the underinsured patient with diabetes.  Patients who needed their blood sugar checked, were hypoglycemic, received treatment and when alert again, would sign the refusal of transportation form.  These trips would often end with a call to a medical control provider but would yield no payment to the EMS service.

For years, we have fought to be recognized as a valued part of the medical team, and this new service model has the possibility of being a giant leap for EMS kind.  Not only does this require the implementation of quality metrics for EMS service but provides paramedics a platform to shine.  EMS providers are now able to highlight their mastery of pre-hospital medicine, human pathology, knowledge of medical protocols, and dedication to patient care, no matter where that care may be delivered.  This is our chance to prove to the world that paramedics and EMTs are capable of quality, evidence based prehospital medical care, and not just basic transport.  With increased power comes greater responsibility and thus the responsibility of advanced education now falls onto the shoulders of my EMS family.  Advanced education, in the form of college degrees or specialty certification, is paramount for providers making definitive decisions for patients, and as professional healthcare providers, we should not fear this change.  At this time, paramedics are faced with the ability to be valued members of the medical community, it is time we seize this moment to bear the responsibility, to ourselves, our patients and our communities.

 As a PA, the ability of alternative (more appropriate) destinations brings the obvious benefit of a decompressed ED waiting room.  Many of my patients are there because they have no other avenues to see a provider.  This new payment model is a way to allow for a more efficient and effective pre hospital triage, and subsequently improved treatment of the 911 patient.  Paramedics in the field would now be able to utilize urgent cares and primary care providers to facilitate the most appropriate level of care, while having the ability to be paid for the services they provide.  It also allows for a closer collaboration opportunity between in-hospital providers and pre-hospital providers via additional resource utilization, such as telehealth.

 Overall I think this is a great leap in the right direction for EMS and the future of our profession.

This new reimbursement model creates standardized benchmarks for the EMS providers.  The goal of which is to improve the quality of care, while decrease the overall cost of healthcare.  It is our responsibility as EMS providers to show that we are worthy of this opportunity and seize it with overwhelming care, compassion, and efficient care for our patients.  It is also our responsibility to make assure we have the education, knowledge and the skills to advance the EMS profession and allow ET3 to be the giant leap forward EMS so desperately needs.  This may also allow for new relationships between EMS providers and hospitals in the region to be formed. It is my hope and belief that this announcement will improve the effectiveness and efficiency of prehospital medical care and allow the continued growth of MIH programs nationwide.

Can ET3 push the field of medical direction to where it should be?

by Melissa Kroll, MD and Hawnwan P. Moy, MD

 Introduction

The Center for Medicare and Medicaid Services’ (CMS) passage of the Emergency Triage, Treat, and Transport model (ET3) not only recognizes EMS as part of the health care system but is a significant step in developing a mature EMS system.  But what does this mean for the EMS medical director?  It is unlikely that we will be notoriously ignored like the 1973 EMS System Act of old. But will it help propel the office of the EMS medical director from an often unpaid (or underpaid) position struggling to fulfill the needs of the EMS system to a widely recognized and valued component of the healthcare system? Before we attempt to answer these questions, let’s review what the ET3 model hopes to establish.

What is ET3?

A new model for prehospital care that allows for increased flexibility and efficiency.

 The ET3 Model is a voluntary, five-year payment model aimed at increasing the flexibility and efficiency of prehospital systems. Essentially, with this trial period, CMS has agreed to pay EMS services for the following:

 1) transport an individual to an emergency department or other destination covered under the regulations

 2) transport to an appropriate destination (such as a primary care doctor’s office or an urgent care clinic)

  3) or provide treatment in place with a qualified health care practitioner, either on scene or connected using telehealth.

ET3 hopes this model will encourage cooperative agreements between local EMS systems and surrounding dispatch systems, hospitals, clinics, local governments, etc. This system also allows for increased accountability of systems through monitoring of programs through specific QI/QA metrics.

Feb 14, 2019. Emergency Triage, Treat, and Transport (ET3) Model. https://www.cms.gov/newsroom/fact-sheets/emergency-triage-treat-and-transport-et3-model

 What does this mean for the Medical Director?

Not just a “sign here Doc” system.

 If we ask any lay person what a good fire or police chief can do for their community, they may not answer with specifics, but they implicitly understand the role of such leadership positions.  If you ask them what a good EMS medical director can do for their community, you’re probably going to get a blank stare. Perhaps we have been too complacent in advertising what it is that a good EMS medical director can do for the EMS service and community.  Let’s take the opportunity now to highlight what a good medical director can do to ensure the success of ET3 and improve community health.   

1. At the heart of it all, a medical director is a physician first.  Physicians have duty to ensure that the patient remains at the center of the system -an active medical director ensures that the patient is always number one.

2. With the ET3 expansion of EMS systems there needs to be increased involvement and oversight by medical directors. As experts in the medical direction and having an intimate knowledge of how hospital systems operate as physicians, medical directors are a required leader for connecting the hospital, EMS systems, local governments, and other entities in a collaborative partnership.

3. Many systems will be creating new processes, such as 911 triage, processes for determining optimum patient destination and who can best be treated in the home. New protocols requiring in-depth physician input will need to be developed, trialed, updated, and re-trialed.

4. Constant quality improvement and quality assessment will need to be completed.  Continuous quality improvement, quality assessment, and timely feedback by the EMS Medical Director are required to ensure the safe medical care of the patient.

5. Results will need to be published, presented, and discussed allowing for programs to learn from each other. Medical directors will need to be present, both in discussions at a higher level, but also on a ground level where practical application occurs to ensure a smooth maturation of the EMS system for the safety of our patients and still receive valuable data.

6. ET3 allows for treatment to occur in the home in coordination with a qualified healthcare practitioner. Behind every prehospital provider that completes an in-home evaluation, there is the medical director who has provided focused, up to date education, training, and consistent quality assessment.

7. In order to provide treatment in place, there will need to be a conversation with a qualified healthcare practitioner. For many systems, this will be a conversation with their medical director. This medical director will need to be accessible for consultation.  

 As a subspecialty of medicine, EMS should optimize the opportunity provided by ET3 to move EMS medical direction from “what is” to “what should be”.   We would be remiss not to recognize that unfortunately the term “medical director” currently describes a wide range of physician roles – from rubber stamp signatures on paperwork unknown personally to frontline providers to those who are involved in all aspects of patient care provided by an agency. The reason for this spectrum in medical direction is multifactorial.   EMS as a medical subspecialty is rather young, although EMS subspecialty fellowship training is working to build a larger base of involved EMS physicians.   At the state, agency or regional level, EMS medical directors are often excluded from decision-making. In addition, many medical director positions remain un- or under-funded and full time or majority time EMS physicians are few among us. Reimbursement rates for medical direction (the cost) largely do not acknowledge the value that an involved medical director can bring to the healthcare system.  This will be even more evident as we consider treat in place and alternative destinations which will better align patient needs with the current financial incentives of the healthcare market. 

The Future

The pilot will end. What needs to happen to make the future successful?

 Will a change in reimbursement structure such ET3 be the nidus to move medical direction to where it should be?  We think it can.   Fundamentally, systems that have relied on rubber stamp physicians will not be able to function in this expanded model.   EMS physicians will need to step up to both this challenge and responsibility.  Hopefully this new model provides a financial means to support them in doing so.

The ET3 is a 5-year pilot project. Which means it will end. In order to make this a sustainable option in the future, medical directors will not only need to be careful trackers of data, allowing for cost analysis of the impact, but leaders who demonstrate wisdom, integrity, and the expertise required to navigate the unique world of healthcare both in and out of hospitals while keeping an ever-vigilant eye on maintaining patient-focused care.  Let’s become the EMS Medical Directors we all strive to be.  

Article Bites #10: Delivering Right Care and Transporting to the Right Place: Medical clearance of Psychiatric Emergencies in the Field

Article: Trivedi TK, Glenn M, Hern G, Schriger DL, Sporer KA. Emergency Medical Services Use Among Patients Receiving Involuntary Psychiatric Holds and the Safety of an Out-of-Hospital Screening Protocol to "Medically Clear" Psychiatric Emergencies in the Field, 2011 to 2016. Ann Emerg Med. 2019;73(1):42-51.

Background & Objectives:

Due to a nationwide shortage of inpatient psychiatric beds, patients with psychiatric emergencies often spend long periods of time waiting in the ED for placement for psychiatric care. These long wait times are associated with more ED overcrowding, increased costs, and unfortunately sometimes inhumane conditions for patients and increased stress for staff. The vast majority of patients with involuntary psychiatric holds are brought to the ED by EMS, usually for medical clearance and evaluation for other possible non-psychiatric causes of the patient’s presentation. This study investigated the role of an EMS field protocol to allow EMS to bypass EDs and transport patients directly to a psychiatric facility. 

Methods:

The investigators conducted a retrospective review of all EMS transports in Alameda County, CA between November 1, 2011 to November 1, 2016, focusing particularly on patients receiving involuntary psychiatric holds. To assess for patients who received involuntary holds, the investigators evaluated the medical priority dispatch system code, primary impression, secondary impression and medical narrative as documented by EMS providers. According to the Alameda County EMS Agency protocol (see further reading below) patients with isolated psychiatric presentations can be transported directly to a stand alone psychiatric facility provided protocol criteria is met. Two primary outcomes were examined. First, the investigators compared “involuntary hold patients” with those patients who never received an involuntary hold to identify what specific characteristics were associated with patients receiving involuntary hold status. The second outcome that was evaluated was the safety of an EMS field protocol to screen patients for direct transport to a psychiatric facility and bypass of the ED. This measure was defined by retransport of a patient to the ED within 12 hours of transport to the psychiatric facility (AKA “failed diversion”).

Key Results:

During the study period, the investigators identified 541,731 total EMS transports (257,725 unique transports). Of the total transports, 10% (n=53,887) were for involuntary holds. The key results from the study were as follows

• 41% (n=22,074) of transports for involuntary hold patients met protocol criteria for ED diversion and direct transport to stand alone psychiatric facility

• Of patients who were transported to stand alone psychiatric facility, 0.3% (n=60) failed diversion and required retransport to ED within 12 hours

• Involuntary hold patients were found to have significantly more total EMS use (24% of all encounters; n=128,003) compared to patients that never received hold status. They were also more likely to be younger, men, and have uninsured status

• Of the patients requiring retransport within 12 hours, 54 of 60 of those patients developed new symptoms on arrival to the facility which did not manifest with their initial presentation to EMS. Reasons for retransport included traumatic injury (n=5), previously unrecognized or unreported symptom (n=13), seizure (n=8), excessive sedation (n=10), staff request for medical clearance of asymptomatic patient (n=7) new mental status change (n=5) or patient discharge from psychiatric service and self referral to EMS (n=5)

Takeaways:

• Over the course of a 5 year period, an EMS field protocol to screen psychiatric involuntary hold patients for direct transport to a stand alone psychiatric facility performed safely, with only 0.3% of transported patients requiring retransport to an ED within 12 hours

• Involuntary hold patients were usually younger and often uninsured. In addition, they had significantly higher overall EMS utilization

What this means for EMS:

This study demonstrates that implementation of an EMS field protocol can allow for safe diversion from ED directly to a psychiatric facility. The implementation of such protocol in EMS systems would likely have a significant impact on ED overcrowding and length of stay. This study highlights two important points: 1) The role of EMS with respect to hospital operations, ED operations and the health care system as a whole cannot be overstated. EMS systems nationwide may be able to build upon the lessons from Alameda County and help reduce ED overcrowding concerns as well as more rapidly direct patients to the psychiatric care they need. 2) EMS utilization by patients with psychiatric illness is significant, with roughly one-quarter of all transports in Alameda County being for “involuntary holds” during the 5 year study period. This further re-inforces the importance of both federal and local resource allocation for psychiatric illness. 

Further Reading: 

Alameda County EMS involuntary hold protocol:

https://www.annemergmed.com/cms/10.1016/j.annemergmed.2018.08.422/attachment/b3ec30ed-3ced-4eca-963b-82a60f05d663/mmc2.pdf

Review and Infographic by Article Bites Editor, Al Lulla MD (@al_lulla)

Article Bites #9: The Emergency within EMS - Risk of Suicide in EMS Compared to the General Public

Death by Suicide — The EMS Profession Compared to the General Public

Vigil NH, Grant AR, Perez O, et al. Death by Suicide-The EMS Profession Compared to the General Public. Prehosp Emerg Care. 2018;:1-6.[PMID: 30136908]

Background & Objectives:

 Suicide is a public health crisis with an estimate 45,000 individuals dying from suicide annually. Certain professions, including law enforcement and EMS are exposed to high degrees of workplace stress, therefore it is hypothesized that these individuals are more predisposed to conditions including anxiety, depression and suicidal ideation and behaviors. Survey data examined by the National Association of Emergency Medical Technicians (NAEMT) has indicated that there is very high occurrence of suicidal ideation within the EMS community. Despite this important information, the relationship between suicidal ideation and suicide attempt with the completion of suicide in EMS providers has not been well studied. The authors of this study aimed to assess the odds of death by suicide completion in EMTs compared to non-EMTs.  

 Methods:

The investigators conducted a retrospective case-control study that analyzed the electronic death registry in Arizona from January 2009 to December 2015. Only adults greater than or equal to the age of 18 were included in the analysis. Multiple variables from the death registry were examined including age gender, race, ethnicity, and most importantly for the purposes of this study: cause of death and occupation. With respect to occupation, the term "EMT" was categorized as all individuals who had EMT certification, including firefighters, EMTs and paramedics. A logistic regression model was implemented to calculate the mortality odds ratio (MOR) of suicide between EMTs (exposed group) and non-EMTs (non-exposed group). 

Key Results:

In total, 350,998 adults were analyzed who died during the above time period. The key results from the study were as follows:

· There were 1,205 EMT deaths during the study period

o   63 (5.2%) were attributed to suicide. This is compared to the non-EMT group of which 2.2% of deaths were due to suicide. 

· MOR for EMTs versus non-EMTs was 2.45; [95% CI (1.88-3.13)]

· Adjusted MOR for EMTs versus non-EMTs was 1.29; [95% CI (1.06-1.82)] adjusted for gender, age, race and ethnicity 

· The most common mechanisms of suicide in the EMT group was firearm (67%), however there was no significant difference between death by firearm in the EMT cohort versus the non-EMT cohort. 

Takeaways:

· In the Arizona electronic death registry, there were higher odds for death by suicide in EMTs compared to the general public. 

What this means for EMS:

EMS providers are faced with significant workplace stressors. Whether it’s traumatic calls, poor sleep quality, poor compensation, long hours, or overall low job satisfaction, EMS remains one of the most challenging professions. These aspects of the EMS profession, unfortunately, contribute to a host of mental health issues including depression, anxiety, PTSD, all of which predispose individuals to developing suicidal ideation and behaviors. The time to act is now. The results of this study are extremely compelling and must serve as the impetus for change within the profession. Further studies that precisely characterize the risk factors that place EMS providers at higher risk than the general public should be examined as well. Despite this, the findings from this research still demonstrate the need for greater EMS education regarding the symptoms and warning signs of suicidal behavior, the importance of adequate resources for counseling and mental health, and improved work conditions to protect those individuals who protect our communities and our patients. 

Article Reviewed by Article Bites Editor Al Lulla, MD.