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ALS
Care
on the
Fire Line
ALS fire line paramedic program
delivers care in minutes p. 22
VEHICLE SPOTLIGHT
Alternative Transport p. 43
Emergency Vehicle
Design Standards p. 48
Ambulance Manufacturer
September 15–19, 2015 | Las Vegas, NV Directory p. 52
EMSWorldExpo.com
THE CLOCK IS
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1Meaney PA, et al. Circulation. 2013;128:417-35
©2014 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a trademark and/or registered MCN EP 1409 0059
trademark of ZOLL Medical Corporation in the United States and/or other countries.

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Contents
APRIL 2015
VOL. 44 | ISSUE 4
CO V ER R EP OR T
22 Delivering ALS Care on the Fire Line

How Kern County, CA, developed an ALS fre line paramedic program
By Barry D. Smith
22
F E AT UR E S COLUMNS
14 CASE REVIEW
Bariatric Patient Care
28 Mobile Integrated Healthcare Part 4: By James J. Augustine, MD, FACEP
Integrating Home Care, Hospice & EMS
Partnerships with MIH-CP programs can help avoid 58 LIFE SUPPORT
EMS.O.S.
needless hospital visits By Mike Rubin
By Meredith Anastasio, J. Daniel Bruce & John Mezo
DEPARTMENTS
43 Alternative Options for Patient 8 EMS World Online
Transport 10 From the Editor
Specially designed ATVs and UTVs enable EMS 12 EMS News Network
providers to access patients virtually anywhere 56 Advertiser Index
By Jason Busch 57 Classifed Ads
43
48 Addressing Ambulance Standards
New ambulance design & safety standards will be in
place by 2016, but what will they look like?
By Jason Busch
52 Ambulance Manufacturer Directory

& Product Showcase
Leading ambulance manufacturers profle their
ON THE COVER
latest vehicle designs and equipment
Kern County, CA, fre crews and
paramedics work together to
CE A R T ICL E move a patient to a helicopter
landing zone during pre-fre
season training. Photo by Barry
33 Diagnosis and Treatment of D. Smith.
the Patient With Heart Failure
What their history and your clinical exam DOWNLOAD the FREE
should tell you about what’s happening EMS World tablet edition
By Scott R. Snyder, BS, NREMT-P, Sean M. Kivlehan, MD, MPH, NREMT-P, app to access exclusive
& Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT EMS World content.
12
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EMS WORLD ONLINE facebook.com/emsworldfans twitter.com/emsworldnews www.linkedin.com/
groups?gid=1853412
NEW
FE ATURES MOULAGE
OF THE MONTH
SPONSORED BY:
Bobbie Merica continues her guide

to simulating injuries and illnesses
through efective use of moulage.
This month: Pediatric stroke.
See EMSWorld.com/12050955
VIDEO OF THE WEEK

EMS World is pleased to announce it has partnered
QUALITY CORNER: with ReelDx, a pioneer of real-patient video in medical
CHECKING OUT education, to publish real-patient video case studies
Except for the actual patient designed to educate EMS providers.
care we render, there is probably The case studies ofer short videos of real
nothing so important as checking encounters in the feld and in emergency rooms,
your ambulance to ensure you are substantial case data and
ready for what may come your imagery, and behind-the-scenes
way. Read more at EMSWorld. insights on the encounter.
com/12050956. Go to EMSWorld.com/video.
PODC A S TS
THE WORLD OF EMS: WORD ON THE STREET: TALKING SMACC WEBC A S TS
SAVING PROVIDERS In this month’s
World of EMS host Word on the Visit EMSWorld.com/webcasts
The World o Street podcast, to access our archives:
Chris Cebollero
f EM
talks to Chris EMS World

THE FUTURE OF CRITICAL
S
Colwell, MD, editorial advisory

medical director for board member CARE TRANSPORT:
Denver Paramedics Rob Lawrence HOW DO WE GET THERE?
and the Denver Fire talks with Ashley Critical care transport has been
Department, as well as director of Voss Liebig, who around for decades, but continues
emergency medicine at the Denver serves on the to be a rapidly evolving area in
Health Medical Center, about the U.S.-based EMS. In this webinar, we will look
recent suicide of Denver Health organizing at the past and growth of the
paramedic Debbie Crawford, who committee Mick Lazell and critical care transport industry and
had worked as a paramedic since of SMACC US Ashley Liebig critical care paramedicine.
the 1980s. They discuss how we (Social Media
can better recognize signs of and Critical Care conference) heading to Chicago in SPONSORED BY:
stress and depression among our June, and to a previous SMACC attendee, Queensland
colleagues and provide resources Ambulance Service ofcer Mick Lazell. Find out
for those who need help. how social media and the #FOAMed movement is
See EMSWorld.com/12047526. transforming how we learn about critical care.
See EMSWorld.com/12053225.

FROM THE EDITOR By Nancy Perry
Talking SMACC
Social Media and Critical Care conference educates through technology
TRADITIONALLY EDUCATION HAS BEEN DELIVERED The viral success of FOAM led to the first SMACC
in a classroom setting by teacher and textbook. But what if (Social Media and Critical Care) conference held in
you could listen to a global subject matter expert stream- Australia, which attracted 600 participants in 2013 and
ing a master class directly into your headphones, or you doubled to 1,200 in 2014. And now, by popular demand,
could establish a study buddy 10 time zones away? How SMACC is coming to Chicago in June 2015 (see www.
about posing a clinical problem or question and getting smacc.net.au). In keeping with its cloud-based origins,
answers and best practices from clinicians from around SMACC is not a traditional conference. The sharp, smart
the world? delivery follows a “Med TED” style of presentation to
This is the concept behind the Free Open-Access enthuse attendees in house and online.
Meducation movement, better known as #FOAMed. In this month’s Word on the Street podcast, EMS World
Conceived in a pub in Dublin, Ireland (where else?), the contributor Rob Lawrence talks with Ashley Voss Liebig,
idea quickly gained traction among physicians, residents who serves on the U.S.-based organizing committee
and students, who started to share problems, questions, of SMACC US, to find out how #FOAMed is transform-
solutions and suggestions using the #FOAMed hashtag for ing how we learn about critical care. See EMSWorld.
easy searching on social media. The movement is made com/12053225. Ashley is also a featured speaker at
up of blog posts, podcasts and videos, with Facebook EMS World Expo, September 15–19 in Las Vegas, NV.
groups and Twitter feeds spreading the message. Registration is now open at EMSWorldExpo.com.
Protect your EMS practitioners and the patients they serve.

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Serving our nation's EMS practitioners

NEWS NETWORK By Susan E. Sagarra
Integrated Patient Transport System

for Missouri Agency
MIKE MCCART, DEPUTY CHIEF OF THE more efficient way to have the supplies set
Pulaski County Ambulance District in mid- up inside the ambulance instead of using
Missouri, wanted to get out of the box, liter- cabinets where medics can hit their heads,
ally, to provide emergency medical services or that can be yanked out in an accident,”
for his community. says McCart. “I had created my own soft
In late February, the district took delivery bag of supplies, but I couldn’t figure out
of a custom-made 2014 Mercedes Sprinter how to hang it up.”
ambulance built by Osage and using a new Ferno convinced Mike to be a beta site
component set from Ferno. The innova- partner in the development of the Ferno
tive design has the safety of medics’ and iN∫Traxx system, which has been designed
patients’ in mind. and tested for mainstream EMS applica-
It is more compact than the typical box- tions using military-inspired technologies.
style ambulance and supply cabinets have Working together, Ferno, Pulaksi and ambu-
been replaced with soft-sided bags. The lance manufacturer Osage brought the first Pulaski County requested a forward-facing
supply bags, monitors, oxygen and IV Integrated Patient Transport System (IPTS) seat instead of the typical side bench seating
equipment hang along the side with quick- to reality. for more safety and better access to the
release mounts on a track system. The design of the IPTS System and ambu- patient and medical supplies.
“It’s the first ambulance of its kind in the lance allows providers to remain safely seat- reach everything they need. Everything,
United States,” says Tim Schroeder, director ed and restrained while performing care including the patient, is accessible from
of ambulance systems for Ferno. “We have and reaching for supplies. “Providers can the seated position.”
spent three years developing the iN∫Traxx be strapped in instead of moving around The ambulance is also equipped with
System. The interior is modular and can be and all the supplies and monitors are locked Ferno’s Acetech system to monitor vehicle
changed around within minutes.” in securely so if there is an accident, things location and support safe driving behaviors.
The Pulaski ambulance began when won’t shift or fly around the back of the Look for a more detailed article about the
McCart wanted to purchase the Ferno- ambulance,” says McCart. “The provider vehicle in the May issue.
Track system that he’d seen in Ferno’s can be strapped into the seat and it moves Susan E. Sagarra is a writer, editor and book author
military equipment. “I was looking for a backward and forward so they can easily based in St. Louis, MO.
Soft-sided supply kits are placed along the tracks system and can A military-style stretcher can be added to the side-tracking system
be catered to specific calls. Oxygen tanks are easily accessible for when it is necessary to transport two patients. This photo also shows
the provider who is seated behind the patient’s head when airway the track and the movable devices that supply bags, monitors and the
management is required. stretcher all can be hooked and locked into for a safer environment.

How do you improve
STEMI outcomes?
Ensure speedy, reliable 12-lead data
transmission with Physio-Control.
We’ve known it for years: Better, faster communication

saves lives. In the past, that was hard to act on in the feld,
due to slow technology and urgent demands on attention.
“I don’t know how
Physio-Control takes the pressure of of EMS teams and you could argue the
makes it easy to deliver high-quality patient data to hospital
caregivers long before arrival. benefts. This system
MONOC and Physio-Control
improves patient
Monmouth Ocean Hospital Service Corporation (MONOC) outcomes by cutting
EMS responds to 325 STEMI calls annually, and was
committed to reducing frst medical contact-to-device times E2B and D2B times.”
as much as possible. To do that, they needed a better way to
transmit patient data—and Physio-Control delivered. —Scott Matin, MONOC Vice President
of Clinical, Education, and Quality
Improvement
The LIFENET® System helped MONOC paramedics send
ECGs from the feld to the hospital more easily and with fewer
steps. That meant multiple transmissions over the course of
travel—and better, faster pre-arrival information. That led
to better overall care for all of MONOC’s STEMI patients.
Bottom line: Physio-Control solutions can help you

reduce D2B and E2B times.
Learn more!
Download the case study at www.physio-control.com/MONOC/
Physio-Control, Inc. Case study: Prehospital 12-lead ECGs help to reduce EMS-to-balloon times. 2014.
©2014 Physio-Control, Inc. GDR 3320169_A
CASE REVIEW By James J. Augustine, MD, FACEP
Bariatric Patient Care

When an obese patient is transported, what can be done with his scooter?
THE LATE-AFTERNOON TRAINING session Initial Assessment

is interrupted by the dispatch tones, and Attack A 38-year-old male in moderate distress,
One is requested to respond for a “person responsive only to painful stimuli. No obvious
unresponsive.” The crew notes an extra piece trauma.
of equipment—a ladder truck—is also asked to
INITIAL ASSESSMENT
respond on this incident. No further information
❯ AIRWAY: Not compromised.
is available.
The scene is at the edge of a downtown ❯ BREATHING: Moderate distress, no wheezing.
park, where a group of bystanders surrounds a ❯ CIRCULATION: Pale, cool skin, no diaphoresis.
patient. The Attack One crew parts the crowd ❯ DISABILITY: Withdraws from painful stimuli.
and finds a middle-aged man who is strapped ❯ EXPOSURE OF OTHER MAJOR PROBLEMS: Found
into a large-person conveyance scooter, unresponsive.
slumped over the steering mechanism. He is
VITAL SIGNS
breathing but pale and withdraws only to pain-
ful stimuli.
TIME HR BP RR PULSE OX.
A helpful bystander reports they noticed the
man coming out of the park on his scooter when 1608 140 Unknown 28 Not
obtainable
he gradually slowed and came to a stop on the
1616 124 80/palp. 24 90%
sidewalk. He lowered his head onto the steering
handle, and bystanders found him to be unre- 1622 124 90/palp. 24 92%
ABOUT THE
sponsive, not just sleeping. No one is familiar 1630 94 130/palp. 24 95%
AUTHOR
with the man.
AMPLE ASSESSMENT
The Attack One crew takes control of the
❯ ALLERGIES: None known.
man’s head. His skin is pale and cool, he is
breathing, and his pulse is palpable at his neck. ❯ MEDICATIONS: None.
He is very large, weighing perhaps 500 lbs. They ❯ PAST MEDICAL HISTORY: No known problems.
find a wallet with his identification but no indica- ❯ LAST INTAKE: Unknown.
James J. Augustine, tion of medical problems or alerts. He lives in ❯ EVENT: Very large patient, with some difficulty
MD, FACEP, is an an apartment near the park. His cell phone is breathing when lying flat.
emergency physician
and the director of
available, and one of the younger crew members
clinical operations opens it and identifies an emergency contact in
at EMP in Canton, the directory, but unfortunately that person is
OH. He serves on
not available when called. altered level of consciousness. She finds no signs of
the clinical faculty in
the Department of The crew members work quickly with the patient trauma; no smell of intoxicating beverages; no track
Emergency Medicine still upright on the scooter. He is maintaining his air- marks; no unusual breath smell; and no diaphoresis.
at Wright State
way, and eventually they want to lie him down, but His pupils are dilated, and his pulse rate is rapid. No
University; as an EMS
medical director for would prefer to have a large stretcher in place before medical alert indicators are present. No insulin pump
fire-based systems in they attempt to move him. is found. A blood sugar is obtained as the crew rap-
Atlanta, GA; Naples,
FL; and Dayton, OH;
“Dispatch, we need an ambulance with a large- idly starts an intravenous line—it’s about 150.
and on the EMS World capacity stretcher sent to our scene,” the paramedic The paramedic ponders a minute. This patient
Editorial Advisory requests. She appreciates the 9-1-1 center has dis- is minimally responsive and has a rapid pulse, low
Board. Contact him at
jaugustine@emp.com.
patched the additional truck company to the call, blood pressure and poorly perfused skin. His lungs
but they will need the larger stretcher to move the are clear. They cannot determine if he has neck vein
patient. distention due to his size. He is not warm to the
Copyright granted for this
article for department use The paramedic moves through a structured physi- touch, nor does he smell like he has an infection.
only up to 20 copies. cal examination to look for the source of the man’s That means he is in shock, with cardiogenic shock or

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CASE REVIEW
anaphylaxis as the only reasonable causes. contact returning the message left on her
With his rapid heart rate, anaphylaxis seems Learning Point phone; she reports she’s the man’s sister.
most likely. Anaphylaxis is a life-threatening condition She lives in the city but will not be able
The paramedic decides to treat this that is sometimes difficult to identify. to join her brother for a couple of hours.
as anaphylaxis, so the intravenous line is Epinephrine is the lifesaving treatment. Importantly, she reports the man has no
opened and a bolus of one liter started, Very large patients require special prepa- medical problems other than his extreme
and an epinephrine injection of 0.5 ml of ration for their treatment, transportation obesity. She is not aware of him being ill
and management of the devices used in
1:1,000 concentration is drawn up. That recently or having any allergies.
their daily activities.
medicine will have to be administered The crew gives her the information
intramuscularly to begin, since the patient’s about the hospital to which they’ll be
skin is not perfusing well and a dose placed then the arm rubbed to improve delivery transporting. She advises that the sib-
subcutaneously won’t likely be picked up of the medicine. The patient’s condition lings’ parents are out of town, and they
and delivered to the vascular system. The doesn’t change. Oxygen is being admin- have a special van the man has to be
paramedic tells the EMTs she will give the istered, and the fluid infusion is going moved in with his high-capacity scooter.
patient 4–5 minutes to respond to the intra- smoothly. They left the area a couple days ago, and
muscular dose; then they will have an intra- When the ambulance with the large- the patient was aware he would not have
venous dose ready for administration. That capacity stretcher arrives, the responders access to a van for about a week. The
gives the crew enough time to do the initial bring the large textile movement tarp over, sister will find a way to contact them and
treatment and then have enough respond- gently roll the patient onto it, then slide him have them call the hospital.
ers and the stretcher available to do a safe onto the stretcher. All hands are used to The patient and stretcher are moved into
removal off the scooter. effect a safe transfer. the ambulance using ramps and a winch.
The IM epinephrine dose is administered A timely phone call then arrives on the As the Attack One paramedic jumps in
into the upper arm with a long needle, and patient’s cell phone. It’s the emergency the ambulance, she notices the large scoot-
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CASE REVIEW
er is the only object being left behind. She very expensive. It cannot be parked on the The pulse oximeter starts giving an audible
asks the captain from the ladder crew if he sidewalk, or something is likely to happen signal.
can find a way to get the scooter to the to it. It has some personal materials left “Sir, you are with metro EMS,” the para-
hospital. with it. The police officer who came to the medic tells him. “You were found uncon-
“Sure,” he replies, “although I have no scene says he has no idea what to do with scious on your scooter, and it appears you
idea how to get that done. It won’t fit on it, and the police department doesn’t have are having an allergic reaction to some-
our apparatus. I’ll try to get the police or a vehicle to transport it. thing. How are you feeling?”
The captain places a call to an EMS “I feel completely washed out. It’s hard
supervisor and asks his crew to hail down to breathe lying on my back. Can you lift
THERE ARE FOUR any metro bus that comes by, so as many my head?”
SUBSTANCES THAT options as possible are explored at the The head of the stretcher is raised slowly,
OFFER “WAKE UP” same time. and the patient reports he feels much bet-
In the ambulance things are going better. ter as it is. His skin begins to pink up, and
OPPORTUNITIES About five minutes after receiving the intra- his radial pulse and the oximeter on his fin-
FOR EMS. muscular epinephrine, the patient begins ger are both responding.
to stir. The paramedic has been mixing up The patient finds a position of comfort
metro bus service to move it there.” But he a solution of epinephrine by taking a vial with his torso upright at about 45 degrees
is fairly sure those will not really be good of epi and injecting it into a smaller bag and asks to remove the oxygen mask. His
options. of intravenous fluids. It is prepared to be pulse is down to a rate of around 120, and
So the ambulance rolls off to the hospital added to the line where the fluid bolus is with the oxygen mask off, his oxygen satu-
emergently, and the captain evaluates his going in. ration is above 90%. The blood pressure is
alternatives. The scooter is large, weighs The patient’s eyes open, and he speaks: palpable at about 80 mmHg. Most impor-
several hundred pounds and is no doubt “What happened? Who are you people?” tant, the patient is now beginning to speak.
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“I felt like I got stung by something as I “Great for you, sir—you seem to be The nurses and patient are asking about
was going through the park. It was on my getting better,” the medic tells him. “The the scooter, as they anticipate he will be
back, so I couldn’t tell what happened. Can emergency department staff will be glad released from the hospital after a few hours
you look to see? I have never had a prob- you’re able to talk with them as we go in. of observation. The EMTs are asked to con-
lem like this before. And I’m starting to feel Our report from the scene indicated you tact the captain to find it. The radio traffic
sick to my stomach.” He advises he has no were unconscious.” has depicted a concerted effort to locate a
chest pain. The gentleman is turned over to ED staff transport vehicle that could safely move the
The paramedic can’t find anything exam- in much better shape than when found. As scooter; in the city’s maintenance division
ining the patient’s upper back but can’t do he is he tells the Attack One crew, “Thank was finally found a medium-duty truck with
a complete exam at this time due to the you for making me feel better. Where is a lift gate that could lift it for transport. The
patient’s size. “We will look again when we my scooter?” scooter is stabilized in the truck’s bed for
get to the hospital,” she tells him. “Before a short ride. The ladder truck follows the
we get there, I’m going to give you some Emergency Department support vehicle to the hospital to ensure
other medicines we use for allergic reac- Management safe movement during the ride, off the
tions. I will also give you some medicine The patient is loaded onto an oversize ED truck and into the ED. The scooter will not
for your nausea.” cot, and during the transfer he is com- fit in the patient’s room, so they park it in
The paramedic administers a dose of pletely disrobed. On his lower back is the ED hallway.
diphenhydramine, a dose of methylpredniso- an area that is raised and inflamed, con-
lone and a dose of ondansetron for nausea. sistent with a bee sting. The emergency Case Discussion
By the time the ambulance arrives at the physician congratulates the EMS team on The “unconscious unknown” patient is a
hospital, the patient is sitting up and com- an outstanding pickup based on clinical significant challenge for EMS providers.
fortable receiving oxygen by cannula. His findings, without a history or physical evi- Lack of known medical history makes it
blood pressure is palpated at 130 mmHg. dence of a sting. even more challenging. Difficulty in being
EMSWORLD.com | APRIL 2015 19

CASE REVIEW
able to obtain vital signs makes things stings and foods. Foods are becoming ers or large wheelchairs for conveyance.
harder still. more prevalent as a cause. These are expensive and cannot be left on
The most common treatable causes of Epinephrine has been used for years in the street or in other public places if the
altered level of consciousness for emergen- emergency care. Recent years have seen patient is transported away. Movement of
cy providers relate to a blood sugar that is the drug placed in the hands of the public those devices cannot be done in an ambu-
low or an intoxicating-substance level that in automated injectors. But the availability lance or a standard supervisor vehicle, fire
is high. Both have characteristic findings on of these auto-injector devices has been engine or ladder truck.
physical evaluation. A glucometer offers a challenged, and the price of the devices Thus agencies may have the opportu-
dramatic improvement in the ability to find has risen dramatically. Some EMS servic- nity to work with a local ambulette service,
abnormal blood sugars, both high and low. es have developed much less expensive metropolitan transit service or other public
A normal sugar allows the EMT the assur- approaches to epinephrine availability for agency to move these devices. There are
ance to look for other causes. EMTs and EMT-Intermediates.1 a variety of events that may require such a
There are four substances that offer EMS providers must be able to provide resource to be readily available. It is cost-
“wake up” opportunities for EMS. These care for very large patients and the devices and time-efficient to have those special
are glucose, naloxone, oxygen and epi- that are used to maintain their health and resources available through mutual aid or
nephrine. The first three are very safe. The prevent injuries. Very large patients have other shared resource agreements.
fourth can have significant complications. the right to emergency care, and provid-
REFERENCE
Epinephrine is lifesaving when given for ers have the responsibility to deliver care 1. Aleccia J. King County drops EpiPen for cheaper kit
allergic reactions. A recent estimate is that without risking injury. with same drug. Seattle Times, January 14, 2015; http://
seattletimes.com/html/localnews/2025464333_
1.6% of persons in this country have had It is beneficial to have resources in the countydropsepipensxml.html.
severe allergic reactions, with the most region to move very large patients and their
frequent triggers being medications, insect devices. Some of these patients use scoot-
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C O V E R R E P O RT
How Kern County, CA,

developed an ALS fre line
paramedic program
K
By Barry D. Smith
ern County is the third-largest county in Califor-

nia. Its 8,000 square miles include the southern
end of the Sierra Nevada Mountains, as well as
parts of other mountain ranges. Steep, rugged
terrain that rises over 8,700 feet is covered with
forest and thick brush. It doesn’t take much imagination to
know that fighting a wildland fire under these conditions
is hazardous. The terrain calls for hard physical labor, with
falling trees and rocks, smoke, snakes and insects presenting
opportunities for injury.
“The Kern County Fire Department (KCFD) has two type-2
hand crews and one type-1 hotshot crew for fighting wildland
fires,” explains Guy Lawrence, EMS coordinator for the depart-
ment. “On many wildland fires, the hand crews are working
in wilderness areas miles from road access. In the past, the
hand crews only had an EMT with a first-aid kit. ALS care
could be hours away. With our fire line paramedic program,
ALS care can now be on scene in minutes.”
About five years ago, there was a request from the federal
government for ALS care on the fire line. This request was
made after an incident at a remote fire where a firefighter was
hit with a snag and bled to death. Due to the heavy smoke,
responders were unable to get a helicopter in immediately.
It took more than three hours to get ALS care to the patient.
KCFD’s hand crews are very active during the fire season,
both in the county and traveling all over the west for large
fires managed by federal agencies, so the department decided
to set up its own fire line paramedic program to provide ALS
care to its hand crews.
“We have about 50 paramedics in our department and
one ALS fire station in a remote area of Kern County,” says
Lawrence. “A private ALS ambulance service has a contract
to provide paramedic service and transport for the rest of
the county. We have a dozen paramedics who develop and
teach our EMT, continuing education and refresher training
for our 550 firefighters. We have 8–10 paramedics involved
with the fire line medic program and another three fire line
Kern County Fire Department medics are assigned to our helicopter program.
helicopters play an important role “We had to get approval to develop the fire line medic
in the fireline medic program. program through our local EMS agency, which is the Kern

County EMS Office. We had to write a fire line medic of county, and the equipment and medications that
protocol and submit it for approval by the county must be carried on the fire line.
EMS office. We also had to get approval from the All the equipment is carried in two packs that are
Kern County EMS Commission. Then it had to go locked in a large toolbox with wheels. The toolbox
to the county board of supervisors through the EMS also carries restock supplies. To function at the
Advisory Board. It was quite a lengthy process and ALS level requires a
took about a year to get everyone’s approval.” team of two people, THE PARAMEDICS CAN GO TO
a fire line EMT and a
Protocols & Equipment fire line paramedic,
ANY FEDERAL INCIDENT IN
The treatment protocols the fire line medics use which is the require- THE COUNTRY AND USE THEIR
are the same as those for all paramedics in Kern ment from the EMS PARAMEDIC PROTOCOLS.
County. One of the major differences is the para- agency. One pack has
medics are covered when they go out of Kern County. BLS gear and the other ALS. They are required to
This means they can go to any federal incident in carry all the same medications as any ALS unit
the country and use their paramedic protocols. in Kern County; they just don’t carry as much.
The fire line medic protocol also outlines training The only things not done are 12-lead ECGs and
requirements, experience requirements to become cardiac pacing. They carry an AED plus a small
a fire line medic, charting requirements when out cardiac monitor, the Philips IntelliVue MP2. This
Photos by Barry D. Smith

Kern County Fire Dept. fireline medics use the Philips IntelliVue
MP2 to monitor cardiac rhythm, BP and SpO2.
weighs about three pounds and has automatic blood pressure

and SpO2 capabilities.
“The fire line medics have to be comfortable working in remote
areas, so we don’t take new paramedics into the program,” says
Lawrence. “They also have to qualify as federal wildland firefighters
with a series of classes, as well as a helicopter crew member class
and the fire line EMT class. As additional training, we are putting
our fire line medics through the Advanced Wilderness Life Support
class, a three-day course on wilderness medicine that reviews the
types of injuries and illnesses a fire line medic might see.
“The fire line medics are not tied to our hand crews when they
go out of the county. The medics are assigned to an incident and
work for the medical unit leader within the ICS system. They may
be assigned to a specific hand crew, but are usually assigned to an
area and cover all the firefighters in that area. As an example, we
had a team of an EMT and paramedic at a remote camp on one
fire for two weeks. When the firefighters at the camp went out to
the line, the medical team went with them.”
Air Support
With large fires lasting many days or weeks, there is a designated
rescue helicopter assigned each day. The goal is to have it equipped

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with a rescue hoist, be able to perform

rescues at night with night vision goggles
and be ALS capable. Unfortunately, that
doesn’t always happen. Often, it is only
capable of BLS care. KCFD has two Bell
UH-1 Huey helicopters that meet the high-
WITH LARGE FIRES

LASTING MANY DAYS
OR WEEKS, THERE IS
A DESIGNATED
RESCUE HELICOPTER
ASSIGNED EACH DAY.
er standard. They have been sending one
out of Kern County to do medical/rescue
© Steve Berry
standbys for the past three fire seasons.
During the 2014 season, they were on
standbys for over 100 days.
“Our helicopter unit did 13 rescues while on out-of-county fires in One in a remote area of northern California involved a firefighter
2014,” says Lawrence. “Three or four were very significant rescues. who was struck by a falling tree. He sustained several fractures with
internal bleeding. This occurred at about 2 a.m. Our helicopter
flew in using night vision goggles and used the rescue hoist to
extricate him. He was then flown to the trauma center in Redding,
CA. We had one of our fire line medics on scene caring for him
and then the paramedic on the helicopter continued care en route
to the hospital. The surgeon who worked on the patient said if it
had taken any longer to get him out, he probably would have died.
“On a fire near Yosemite National Park, another tree fell and
hit a firefighter who sustained several cervical fractures. Again,
it was at night in remote, steep terrain. Ground evacuation would
have taken many hours. A KCFD helicopter was on standby for
that fire and had the patient at a trauma center within an hour of
injury. Outside of Southern California, where many fire depart-
ment helicopters are ALS, there are not many fire ALS helicopters
with our capabilities. So we find our helicopter being requested
for federal fires to act as the medical/rescue aerial resource.
“The best advice I can give for other departments that want to
set up a similar program is don’t reinvent
the wheel. Call someone who has already
done it and get their input. I get calls on
a regular basis from other departments
ABOUT THE
asking us about our program. Start early
AUTHOR
because it takes time to work through Barry D. Smith is
all the regulatory agencies. an instructor in the
Education Department at
“The program has been phenom-
the Regional Emergency
enal and we have had some very good Medical Services
patient outcomes, especially with the Authority (REMSA) in
Reno, NV. Contact him at
rapid transport capabilities with the
bsmith@remsa-cf.com.
helicopter component.”

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MIH PARTNERSHIPS
Integrating Home Care,

Hospice & EMS Mobile
Integrated
Partnerships with MIH-CP programs can help Healthcare:
avoid needless hospital visits Part 4
By Meredith Anastasio, J. Daniel Bruce & John Mezo
T
he rapidly changing dynam- healthcare system, not replace health- in today’s new healthcare environment.
ic of America’s healthcare care system resources already available MedPAC (the Medicare Payment
system has created new in the community. Home health and Advisory Commission) is recommend-
expectations for many pro- hospice are valuable links in the chain of ing to CMS that home health agencies
viders. The drive to achieve healthcare—and, for qualifying patients, also receive penalties for patients who
the Institute for Healthcare Improve- a logical care delivery model that can be return to the hospital. The policy rec-
ment’s Triple Aim—improved care enhanced through partnership with the ommendation outlines a savings to the
experience for the patient, improved local EMS agency. Medicare program. The estimate for this
population health and reduced costs— The following are some examples of savings, if approved in 2015, is between
has fostered the creation of many how home health and hospice agencies $50 million and $250 million. MedPAC
innovative partnerships designed to have integrated with their local EMS suggests with the growth in healthcare
enhance healthcare across the con- provider to create significant benefits utilization and the growing population
tinuum. This column focuses on the for both the agencies and their patients. that penalties to home health agencies
synergistic relationships and integra- for readmissions could save as much as
tions developing between EMS-based Increased Referrals $1 billion dollars by 2020.1 The financial
mobile integrated healthcare (MIH) Home health providers are increas- penalties to hospitals from one of their
and the home healthcare industry. ingly being challenged by hospitals and primary referral sources as well as pro-
One of the main goals of EMS-based insurers to reduce preventable emer- posed changes related to hospital read-
MIH is to navigate patients through the gency department visits and hospital missions pave the way for partnerships
admissions. Patients receiving home in communities across the United States.
B
health services tend to have multiple While home care agencies instruct
eginning in January, EMS World chronic diseases with polypharmacy patients to call them for any changes in
launched a yearlong series that pro- and are at significant risk for ED visits their condition and routinely staff regis-
vides readers with a road map for and hospital admissions. Under the tered nurses 24/7, 365 days a year, often
developing MIH-CP programs. This series transitioning healthcare system, hos- patients and families call 9-1-1 out of
will address the following topics: pitals are held financially accountable panic as opposed to true medical emer-
• Planning for rapid implementation; for certain unplanned readmissions. gencies. Developing a partnership with
• Data metrics and outcome measures; And, if the hospital is part of a risk- EMS first responders in the home care
• Updates on CMS Innovation Grants; sharing financial arrangement such service provides an opportunity for the
• Accreditation of MIH-CP programs; as an ACO, they are financially at risk home care on-call registered nurse to be
• MIH Summit at EMS On The Hill Day; for the admission. Consequently, they notified by the first responder while they
• Payer perspectives for MIH-CP services; desire to refer eligible patients to home are en route to the patient’s residence.
• Choosing practitioner candidates; health agencies that can ensure the Klarus Home Care has this type of
• Education of MIH-CP practitioners; patient safely transitions to the home innovative partnership with MedStar
• MIH-CP programs in rural settings; environment without returning to the Mobile Healthcare in Fort Worth and
• International models of MIH-CP. hospital unnecessarily. A home care surrounding areas. MedStar enrolls
This month we discuss collaborations with agency that can appropriately prevent Klarus patients who are in their first-
home healthcare. unnecessary ED visits and admissions responder service area into their data-
gains an advantage over other agencies base, which allows the call center to

Dependability. Versatility. Simplicity.
The HALO Vent creates an occlusive, yet vented seal for open
or sucking chest wounds, stab wounds or other trauma which
could lead to tension pneumothorax. It aggressively adheres
and conforms to a patient’s body and allows for the release of
gases and fluids. The HALO Vent was developed to withstand
wet/extreme environments and is used by EMS, military and
law enforcement services.
• Each package contains two seals (1 vented) to treat both entrance and exit wounds
• Total occlusion even with excessive blood, dirt or heavy perspiration present
• Large pull tab facilitates easy, quick application
• Durable protective packaging that maintains integrity when folded
• Manufactured in the United States; 3-year shelf life
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MIH PARTNERSHIPS
identify that a patient who calls 9-1-1 is on home to the healthcare system. Additionally, many times
health services with Klarus. In addition to sending the home health agency doesn’t become aware the
an ambulance, MedStar also dispatches a specially patient is in the hospital until the nurse goes to the
trained mobile healthcare paramedic (MHP) to the house for a regularly scheduled visit. This creates lost
scene. The on-scene MHP then works directly on the productivity for the home health agency.
phone with the Klarus Home Care RN to do real-time Further, it may at times be logistically difficult for
care coordination for minor medical issues. Perhaps a home care agency to make it to a patient’s house
the patient can be episodically managed at the scene at 2 a.m. or on weekends for an unscheduled visit.
with a follow-up visit by the nurse, thereby preventing Nurses available to make these visits in the middle
an avoidable ED visit or hospital admission. of the night may also be concerned about safety in
Hospitals are looking for home health providers certain parts of the community. Working with EMS
who are utilizing innovative approaches and whose gives the home care agency additional support for
data can demonstrate a reduction in avoidable hos- their current services.
pitalizations. Partnerships between EMS providers Consider the accompanying real scenarios of
and home health companies can pave the way to pro- patients enrolled in the Medstar MIH programs with
viding a more value-based service that drives down Klarus Home Care and VITAS Healthcare. Both of
overutilization, resulting in lower costs. Klarus Home these examples demonstrate the value to the patient,
Care absorbs the costs in their partnership with the the home health agency, the hospital and the over-
first responders to accomplish the goal of reducing all cost to the healthcare system. Integrated mobile
hospitalizations from 9-1-1 calls. healthcare in the Fort Worth market changes the
In some cases, when EMS is going through the EMS incentive.
intake process, the mobile healthcare paramedic
trained in patient navigation and program eligibil- EMS-MIH and Hospice Care
ity may identify that the patient qualifies for home The goal of the hospice agency is to help the patient
health. In this case the MHP can suggest to the at home transition to their afterlife with comfort and
patient’s physician that a referral to a home health compassion. The family is instructed in the proper
provider may be appropriate. way to access the hospice nurse if the patient begins
to struggle at home. Unfortunately, in the panic of
Gained Operational Efciency seeing their loved one struggle, many families call
Home care agencies not partnered with EMS are 9-1-1. This starts a domino effect. The EMTs and
often unaware when their patients call 9-1-1 and are paramedics assess the patient and find them in clini-
taken to the emergency room. The opportunity for the cal distress. The family is scared and cannot locate
patient to be treated in the home, the least restrictive the DNR. EMS does what it’s trained to do: Start
environment, is lost. This has a direct impact on the treatment and take the patient to the ED. Once in
home care agencies’ performance and the overall cost the ED, the hospital initiates care and the family may
Klarus Home Care & EMS Partnership—Actual Patient Experience

• 67-year-old male, DX of cardiomyopathy, chronic heart • MedStar verifies CHF orders in Klarus electronic medical
failure, pleural effusion, diabetes type II. record and consults EMS medical director.
• Exacerbation of CHF 2x in last 60 days; TX by RN using • IV Lasix administered.
Klarus CHF protocols: 40 mg IV Lasix. • MedStar provides follow-up visit later that night, checks
• Patient calls 9-1-1 due to exacerbation, does not call Klarus. potassium, consults on-call physician and adjusts patient’s PO
• Patient IDs as registered Klarus client in 9-1-1 computer potassium.
system. Specially trained MedStar paramedic added to 9-1-1 • Klarus RN follows up with patient the next morning.
response, on-call Klarus RN notified of response while units
OUTCOME:
en route.
• CHF patient not transported to emergency room.
EMS CARE COORDINATION WITH KLARUS: • CHF exacerbation signs and symptoms eliminated.
• Paramedic on scene assesses patient and contacts RN. • Klarus Home Care & MedStar coordination prevents hos-
• Assessment reported to RN: patient short of breath, legs pitalization.
swollen, edema 3+. • Healthcare system cost savings: $9,203.
• RN advises specially trained paramedic to use CHF proto-
col and administer 40 mg IV Lasix.

SEPTEMBER 16, 2015 • LAS VEGAS, NV
Hosted by NAEMT’s PHTLS Committee and EMS World Expo
It will change the way you practice.

Care of the injured is being transformed—you can’t afford not to keep up.
Attend the World Trauma Symposium to learn how trauma care will be
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MIH PARTNERSHIPS
VITAS Hospice & EMS Partnership—Actual Patient Experience

• Priority 1 9-1-1 call from caller identified as VITAS hospice • The client is on oxygen and relates that prior to EMS
client in 9-1-1 CAD. arrival she took something for her spasms but is unable to
• Specially trained MHP added to response. determine what.
• MHP arrives on scene to find patient home alone. • Relates she feels much better now that she has her oxygen
• Patient relates she became anxious and short of breath on.
and is unable to move from chair to turn on her oxygen. • MHP releases ambulance and FD unit, waits for caregiver
• Client appears to be weak with limited mobility due to to arrive and explains the situation.
advanced Parkinson’s. • Also speaks with VITAS triage nurse.
• Paperwork for VITAS is laid out on table with signed DNR. • Patient left in care of caregiver.
• She has around-the-clock care with providers obtained by • VITAS does a home visit later in the day.
her family, but they leave Saturday mornings and are not gen-
OUTCOME:
erally back until the afternoon.
• Patient stabilized and made more comfortable.
• Patient relates her caregiver is off today and she is sup-
• Wishes of patient and family met.
posed to have a substitute arrive at 11 a.m., but they are late.
• Transport to ED, admission and potential voluntary disen-
EMS CARE COORDINATION WITH VITAS rollment avoided.
• On-scene MHP speaks with VITAS triage nurse and dis- • Care coordinated with VITAS.
cusses the situation.
decide this is all too overwhelming and voluntarily VITAS nurse to have the patient transferred from
disenroll the patient from hospice. This is not in the home to an inpatient hospice unit.
best interests of the patient or the hospice agency. Under this program, in place since 2013, 168
The patient’s wishes are not fulfilled; the hospice patients identified by VITAS as being at high risk
agency now has ambulance and ED bills to pay and for voluntary disenrollment have been enrolled by
ABOUT THE loses the per-diem fees normally available had the VITAS. These patients generated 49 EMS calls, but
AUTHORS patient stayed on service. only 29 were transported. Twelve were transferred to
Meredith Anastasio is In Fort Worth we see a different outcome from the an inpatient hospice unit; 17 were transported to the
the managing director same scenario thanks to an innovative partnership ED at the insistence of the family and subsequently
at Lincoln Healthcare with VITAS Healthcare. When the family calls 9-1-1, voluntarily disenrolled from hospice (10%). The rest
Group (LHG) and leads
the planning of Home the computer-aided dispatch system notifies the 9-1-1 died peacefully at home in the presence of the hospice
Care 100 and Home Care call-taker that this patient is enrolled in the VITAS nurse and/or the MedStar MHP.
& Hospice LINK. partnership. This causes an alternative domino effect: Another benefit for VITAS from this program
J. Daniel Bruce is the A hospice-trained MHP joins the ambulance response has been increased referrals. The MedStar MHPs
administrator of Klarus
Home Care in Fort
team, and the patient’s hospice nurse is notified of have been trained in the IHI Conversation Project
Worth, responsible the response. When the MHP arrives on the scene, and can work with patients enrolled in their other
for the ongoing they assess the patient and determine if the clinical MIH programs (such as the service’s high-utilizer or
relationship with
MedStar, and a leader
issue is part of the hospice plan of care. If so, they CHF readmission-prevention program) who may be
in the development of then access the patient’s comfort pack, alleviating the appropriate for enrollment in palliative care. Often,
partnerships to create patient’s suffering; remind the family of as the relationship between the patient, patient’s
value-based services.
the goal of hospice care and the wishes family and MHP evolves over a series of home
John Mezo is the
of the patient; and inform them the visits, the MHP can successfully introduce
general manager of
VITAS Healthcare in hospice nurse is on their way. They Next Month: the conversation the patient or family was
Fort Worth. In this
role he manages all
offer to wait with the family until MIH-CP Program not ready to have while in the hospital.
the hospice nurse arrives and release These are just a few examples of how
aspects of VITAS’
the ambulance back into service. No
Accreditation EMS-MIH and home health can work col-
program, overseeing
program operations, transport, no disenrollment and the laboratively. It is not a competitive relation-
developing business
patient’s wishes are achieved. ship, but a cooperative one designed to meet
opportunities, hiring
and mentoring new In the event the patient’s condition the needs of the patient.
staff and representing on scene is such that management at
VITAS throughout the REFERENCE
home is not practical, care coordination 1. www.medpac.gov/documents/reports/mar14_ch09.pdf?sfvrsn=0.
community.
occurs between the MHP on scene and the

To take the CE test that accompanies this article and receive 1 hour of CE credit
CONTINUING EDUCATION accredited by CECBEMS, go to rapidce.com. Test costs $6.95. Questions?
E-mail editor@EMSWorld.com.
What their history and your clinical exam should tell

you about what’s happening
By Scott R. Snyder, BS, NREMT-P, Sean M. Kivlehan, MD, MPH, NREMT-P, & Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT
H
eart failure (HF) is a common medical 782,985 persons, we can determine that 7.7% of all CONTINUING
problem in the United States. It’s expe- cardiovascular deaths in 2012 were from HF.9 While EDUCATION
rienced by approximately 5.1 million survival rates for persons with HF have improved, the This CE activity is approved by
persons, with more than 650,000 new absolute mortality rates for HF are approximately EMS World, an organization
accredited by the Continuing
cases diagnosed annually.1–3 The inci- 50% within five years of diagnosis. 3,10 Education Coordinating
dence of HF increases with age,2 and for Americans This month’s EMS World CE article uses three case Board for Emergency Medical
Services (CECBEMS), for 1 CEU.
over 40 the lifetime risk of developing HF is 20%.4 It scenarios to explore the evaluation and prehospital
OBJECTIVES
occurs most frequently among black men and least treatment of the patient with HF. These cases explore • List causes of both systolic
frequently in white women.5 the clinical context of all the elements of the history heart failure and diastolic
heart failure.
HF is the primary diagnosis in more than a million and clinical exam to form a “big picture” understand-
• Describe the pathophysiology
annual U.S. hospital admissions.1 Patients admitted ing of the event, and also discuss the appropriate of left heart failure and right
for HF are at risk for rehospitalization, with a one- management of the patient with chronic and acute heart failure.
• Identify the signs and
month all-cause readmission rate of about 24% and HF in the prehospital setting. symptoms of heart failure.
a six-month rate greater than 50%.6–8 • Explain the management of
There were 60,341 deaths from heart failure in Pathophysiology the patient in heart failure.
U.S. in 2012, the last year for which data is available.9 Heart failure is the inability of the heart to produce
Considering that in 2012 cardiovascular disease (the adequate cardiac output to meet the perfusion and
leading cause of death in the U.S. that year) killed oxygenation requirements of the body’s tissues. It is
Systolic Heart Failure Normal Heart Diastolic Heart Failure

Less
blood
flls the
ventricles Fran Milner, www.franimation.com
Less blood Weakened heart Stif heart

pumped out muscle can’t muscle can’t
of ventricles squeeze as well relax normally

CONTINUING EDUCATION
a complex clinical syndrome that can arise • Diastolic dysfunction, the result of cardiac output (CO) and subsequent low
from any structural or functional cardiac abnormal cardiac relaxation, stiffness or blood pressure. Patients with SHF also have
disorder that impairs the ability of the ven- filling. a decreased ejection fraction (EF). The EF
tricle to fill with or eject blood, resulting in is the percentage of blood pumped out of
decreased cardiac output. 5 There are two Systolic Heart Failure the ventricle with each heartbeat. A healthy
mechanisms by which HF can occur: In systolic heart failure (SHF), the heart adult would be expected to have an ejection
• Systolic dysfunction, the result of has impaired contractile function, result- fraction between 50%–75%. A patient with
impaired cardiac contractile function; or ing in a decreased stroke volume (SV) and an EF less than or equal to 40% is said to
have HF. 5
A number of factors can lead to impaired
myocardial contractile function. Acute
Did you know that 74% myocardial infarction (AMI) can acutely
lead to impaired contractility, as infarcted
of EMS worker deaths are myocardium is significantly weaker than

healthy myocardium. After an AMI the
transportation-related?* scarred, remodeled ventricular myocardium

will have less contractile force than healthy
TABLE 1: RISK FACTORS FOR

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• Tracking system allows access to myocardium. Dilated cardiomyopathy can
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• Available in 36” or 48” long track chronic hypertension.
• Seat attachment to base may be Chronically increased blood pressure
offset to gain additional space stretches and dilates the ventricular tis-
sue, making it weaker. Valvular disease
*According to the National Association of EMS Physicians.
and ineffective heart valves can allow the
retrograde movement of blood during sys-
tole, resulting in decreased SV. In addition,
S EAT OP TIONS faulty heart valves (such as the aortic and
Tilt-forward to transport a pulmonary semilunar valves) can impede
track second patient or fip-up
ng the forward movement of blood, resulting in
8” lo when not in use
or 4 decreased SV as well as increased intraven-
36”
tricular pressures, which can cause further
problems such as cardiomyopathies.11
What are you doing to keep your medical staff safe? Diastolic Heart Failure
Specify EVS seating in your next vehicle. In diastolic heart failure (DHF), the ven-
tricle wall cannot adequately relax, result-
ing in inadequate ventricular filling during
diastole and a subsequent decrease in SV
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ventricular relaxation that occurs during maintain adequate CO and effectively move the surrounding tissues, resulting in fluid
diastole. Numerous etiologies can lead to blood forward. This can occur as a result buildup (edema). Left untreated, this will
ventricular wall stiffening. Chronic hyper- of SHF or DHF mechanisms. As a result, lead to pulmonary edema and congestive
tension can result in ventricular hypertro- blood and pressure back up into the vena heart failure. Rales, or crackles, are the
phy as the ventricle is chronically pushing cava. Increased pressures in the superior hallmark finding associated with LSHF.
against an elevated systemic blood pressure vena cava carry over to the jugular veins, The pulmonary edema present in LSHF
and increased afterload. In amyloidosis, leading to jugular venous distension (JVD). occurs for the same physiologic reasons as
protein is deposited in the ventricular wall, Increased pressures traveling down the infe- the ascites and peripheral edema of RSHF.
causing it to stiffen. Patients with DHF do rior vena cava lead to clinical exam findings Left unchecked, left heart failure will lead
not suffer a marked decrease in their EF.5 such as hepatomegaly, ascites and peripheral to right heart failure, as pressure backs up
(pedal) edema. through the pulmonary vasculature and
EMS Perspectives into the right ventricle.
These mechanisms are typically not appar- Left-Sided Heart Failure
ent to the prehospital provider managing a Left-sided heart failure (LSHF) occurs when Case #1
patient in the field. From an EMS perspective the left ventricle can no longer maintain It’s 1152 hours. You and your partner are
it makes more practical sense to approach adequate CO and effectively move blood dispatched to a residential address in a
heart failure via the concepts of right-sided forward. As with RSHF, this can occur as retirement community for a patient com-
HF versus left-sided HF, which are clinically a result of SHF or DHF mechanisms. Blood plaining of weakness. A 66-year-old obese
distinctive and apparent to EMS. and pressure then back up into the pulmo- male presents conscious and alert to person,
nary circulation, leading to increased capil- place, time and event; sitting upright on his
Right-Sided Heart Failure lary pressure, capillary dilation and conges- couch, he complains of dyspnea, dizziness
Right-sided heart failure (RSHF) occurs tion. Increased capillary pressures result in and weakness with exertion. He says he
when the right ventricle can no longer the leaking of fluid from the capillaries into first noticed these symptoms about two

weeks ago and that “it seems to be getting tended and his liver is palpable and large,
TABLE 2: CLASSES OF DIURETICS
slowly worse every day.” Today the patient and he reports pain with palpation. When
USED TO TREAT HEART FAILURE
experienced “the worst weakness I’ve felt you press on his liver, his JVD becomes more
Loop Diuretics: Furosemide (Lasix),
yet—I almost passed out” while walking Bumetanide (Bumex, Burinex), Etacrynic
pronounced. His vital signs are: HR, 72/min.
home from a market around the corner. acid (ethacrynic acid, Edecrin), and regular; BP, 152/90 mmHg; RR, 22/min.
He says his symptoms are “not the same as Torasemide (torsemide) with good tidal volume; SpO2, 90% on room
my COPD when it gets bad,” so he doesn’t Thiazides: Hydrochorothiazide (HCTZ) air; sidestream EtCO2, 34 mmHg with a very
think it’s that. Potassium-Sparing Diuretics: slight “shark fin” waveform morphology. A
While at rest on his couch, he denies any Spironolactone (Aldactone), Amiloride 12-lead ECG reveals a sinus rhythm with
chest pain, pressure or discomfort. He also (Midamor), Trimterene ((Dyrenium) dominant R-waves in V1 and V2, promi-
denies any difficulty breathing, weakness, nent S-waves in V5 and V6, and increased
dizziness, abdominal or back pain, head- cant for COPD and hypertension, and he is amplitude of the P-wave in lead II.
ache, nausea or vomiting. “It all goes away a 102-pack-year smoker. His medications What is your best guess as to the etiol-
as long as I’m resting,” he says. His wife, include a Combivent (albuterol/ipratropi- ogy of the patient’s dyspnea, weakness and
present on the scene, adds that the patient um) MDI and lisinopril. He has no known dizziness with exertion? What history and
has been tired, which is not normal for him, drug allergies. Your clinical exam reveals clinical exam findings help you narrow your
and has been complaining of abdominal jugular venous distension, bilateral lower differential diagnosis? How would you treat
pain over the same period as his symptoms. 2+ extremity edema from the knees to feet, this patient?
Hearing this, the patient adds, “Oh, yeah, my sacral edema and skin that is warm, pale
belly’s been hurting and getting bigger—it’s and dry. Discussion
been swelling. So have my legs and scrotum, Auscultation of his lungs reveals slight This patient shows the history and clinical
but that’s not what’s bothering me now.” expiratory wheezing in all fields, with good exam findings characteristic of right-sided
The patient has a medical history signifi- air movement. You note his abdomen is dis- heart failure. It is most likely the result of his
EMS1504

COPD, a condition termed cor pulmonale. pressure, is palpated firmly. In addition, The 12-lead ECG of a patient with cor
COPD results in pulmonary hypertension, the patient described some upper right pulmonale may exhibit findings suggestive
which causes a resistance to blood flow quadrant abdominal pain, common with of the disease. These include right bundle
through the pulmonary capillaries. Pressure hepatomegaly in RHF. The patient also branch block, right axis deviation and signs
then backs up into the right ventricle, result- exhibits peripheral edema. We would not of both right ventricular hypertrophy (RVH)
ing in either ventricular hypertrophy or expect to find sacral edema in this patient, and right atrial enlargement. ECG findings
dilation. As the right ventricle becomes as he is normally ambulatory and sacral characteristic of RVH include a right axis
affected, pressure further backs up into and edema is more common in patients who deviation of 90-plus degrees, dominant
dilates the right atrium and eventually backs are bedridden. R-wave in V1 and V2 (more than 7 mm
up into the venous system as well. The patient’s dyspnea, dizziness and tall), and prominent S-waves in V5 and V6
There are three manifestations of weakness with exertion are characteristic of (more than 7 mm tall). Evidence of right
volume overload in patients with HF: chronic and worsening RHF. This occurs as atrial enlargement includes a greater than
peripheral edema and elevated venous a direct result of the inability of the diseased 2.5 mm increase in the amplitude of the
pressures in patients with RHF, and pul- right ventricle to increase cardiac output P-wave in leads II, III and aVF.14,15 Other
monary congestion in patients with LHF. during periods of high demand. Everyday cardiac rhythms associated with cor pul-
The patient in Case #1 exhibits these first activities such as walking and working monale include wandering atrial pacemaker
two manifestations. His JVD and enlarged become difficult. and multifocal atrial tachycardia.
liver are the result of the elevated venous There are many risk factors for heart fail- The prehospital treatment of the patient
pressures present when the weakened right ure present in this patient’s medical and with right heart failure and cor pulmonale
ventricle cannot move blood forward. He social history. He has been a heavy lifetime centers on a number of goals:
also exhibits a hepatojugular reflux, vis- smoker and has COPD, putting him at risk • Ensuring airway patency;
ible as a pulsatile wave in the jugular vein for cor pulmonale. In addition, he is obese • Ensuring adequate oxygenation and
when the liver, engorged with blood and and has a history of hypertension. ventilation;

• Assessing for STEMI and monitoring For patients experiencing hypotension receptor agonist with very mild effects,
the cardiac rhythm; with RHF and cor pulmonale, right ventric- offering the desired increases in inotrophy
• Gaining intravenous access; ular contractility can be increased with the (alpha and beta effects) without the undesir-
• Reducing the pulmonary artery pres- administration of an inotropic agent such able increases in SVR (alpha effects). Doses
sure (reducing right ventricular afterload); as dopamine or dobutamine. Dopamine, at up to 15 mcg/kg/min. increase cardiac con-
• Improving right ventricular contrac- intermediate doses (3–10 mcg/kg/min.), is a tractility without greatly affecting SVR.17
tility. beta-1 adrenergic receptor agonist and pro- The patient in Case #1 does not require
Assessment of the airway, supplemental motes norepinephrine release. This results aggressive prehospital management.
oxygen administration and assisted ven- in increased cardiac contractility and chro- Arguably, with a history of COPD and SpO2
tilation via bag-valve mask or CPAP of 90% on room air, he should not be
should be routine in all patients with ROUTINE ADMINISTRATION administered supplemental oxygen
HF when indicated. The 2010 Heart because of the dangers involved with
Failure Society of America guidelines
OF SUPPLEMENTAL OXYGEN giving that to chronic CO2 retainers.
state that routine administration of IN THE ABSENCE OF HYPOXIA Likewise, with a blood pressure of
supplemental oxygen in the absence IS NOT RECOMMENDED. 152/90, he does not require blood pres-
of hypoxia is not recommended.16 sure support with an inotropic agent.
Supplemental oxygen administra- This patient should be placed on the
tion is recommended if hypoxia is present. notropy, increased CO and mild increases cardiac monitor and have a 12-lead ECG
Administration of supplemental oxygen will in systemic vascular resistance (SVR). At performed. Intravenous access should be
result in a reduction in pulmonary artery higher infusion rates (10–20 mcg/kg/min.), obtained and no fluid administration pro-
pressure, as the correction of hypoxia will potent vasoconstriction occurs secondary vided. In addition, a breathing treatment
reverse any hypoxic vasoconstriction that to alpha-1 adrenergic receptor agonism. with nebulized bronchodilators and/or
has occurred. Dobutamine is a beta-1 and -2 adrenergic anticholinergic can be considered, as he
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has a history of COPD, slight wheezing in to use pillows to prop herself up “so I didn’t Her vital signs are: HR, 102/min. and regu-
all lung fields and presents with a slight feel like I was suffocating.” Eventually she lar; BP, 230/110 mmHg; RR, 26/min. with
“shark fin” waveform on capnography. He gave up trying to sleep and moved to her good tidal volume; SpO2, 84% on room air;
should be placed in a position of comfort living room chair. Her breathing got worse EtCO2, 56 mmHg with a normal waveform.
and monitored en route to an emergency throughout the night and she was unable to A 12-lead ECG reveals sinus tachycardia
department for evaluation. get up to use the bathroom this morning, with ST-segment elevation of 2–3 mm in
so she called 9-1-1. She tells you, “I can’t leads V4, V5 and V6.
Case #2 breathe when I try to get up and walk, and What is your best guess as to the etiol-
It’s 0530 hours. You and your partner are I feel like I am going to pass out.” ogy of the patient’s dyspnea, weakness and
dispatched to a residential address for a The patient denies any chest pain, diz- dizziness with exertion? What history and
patient with difficulty breathing. A 56-year- ziness, weakness, nausea or vomiting, syn- clinical exam findings help you narrow your
old female presents conscious, alert and cope, abdominal or back pain. Her past differential diagnosis? How would you treat
oriented to person, place, time and event. medical history includes hypertension and this patient?
She sits upright in a chair in obvious respi- a myocardial infarction three years ago with
ratory distress and says, “My breathing is stent placement in her left coronary artery. Discussion
really bad.” You note from the door that Her medications include ASA, nitroglycerin This patient is a classic example of left-
she is tripoding, using accessory muscles as needed, Bumex, enalapril and verapamil. sided heart failure secondary to AMI. As
to breathe and has pale skin. She has no known drug allergies. Your clini- such, we can classify her as probably hav-
Her difficulty breathing started at around cal exam reveals rales in the middle and ing systolic heart failure, though that will
1700 yesterday afternoon, and she also upper lung fields, with no air movement not change our management approach.
reports that she experienced “some pres- to the lung bases bilaterally. Her skin is Recall from Case #1 the three manifesta-
sure in the middle of my chest.” Last night cool, pale and slightly diaphoretic. JVD is tions of volume overload in patients with
she was unable to sleep lying flat and had present, but there is no peripheral edema. HF: peripheral edema and elevated venous
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pressures in patients with RHF, and pul- in an upright position. Sitting upright allows the patient with left heart failure centers
monary congestion in patients with LHF. gravity to pool and consolidate the edema at on a number of goals:
This patient exhibits the pulmonary edema the bases of the lungs, allowing for optimal • Ensuring airway patency;
characteristic of LVHF. This edema, or con- (considering the circumstances) ventilation • Ensuring adequate oxygenation and
gestion, is what gives rise to the term con- of the alveoli and gas exchange. This patient ventilation;
gestive heart failure (CHF). CHF can result also presented with JVD on clinical exam • Sitting the patient upright;
from LHF (pulmonary congestion) as well but no peripheral or sacral edema. JVD is • Assessing for STEMI and monitoring
as RHF (hepatic congestion). Her left ven- not an uncommon assessment finding in the cardiac rhythm;
tricle, already weakened from a previous MI patients with LHF and pulmonary edema, • Gaining intravenous access;
and now weakened with an evolving AMI, as the increased pulmonary capillary pres- • Diuretic therapy;
cannot adequately pump blood forward in sure leads to increased pressure on the right • Vasodilator therapy.
the cardiovascular system, resulting in a side of the heart as well. JVD occurs rapidly The patient is in obvious moderate-to-
backup of blood and pressure through the in patients with increased right-sided atrial severe respiratory distress but still ven-
left atrium and into the pulmonary circula- and ventricular pressures. Pedal and sacral tilating adequately, making her a perfect
tion. Increased pulmonary capillary pres- edema take longer to develop. candidate for CPAP. Ideally, CPAP could
sures force fluid out of the vasculature and Note that she takes Bumex, a diuretic, be administered with titrated oxygen at an
into the interstitial spaces and alveoli of the and enalapril, an ACE inhibitor, both com- FiO2 sufficient to correct hypoxia but not
lungs, resulting in pulmonary edema. monly prescribed to treat hypertension and overoxygenate. CPAP decreases the need
The patient exhibits many of the clas- heart failure. for intubation and improves respiratory
sic signs and symptoms of CHF, including The 12-lead ECG acquired in this case parameters such as heart rate, dyspnea,
orthopnea (difficulty breathing while lying helps with understanding the mechanism hypercapnia and acidosis in patients with
supine), paroxysmal nocturnal dyspnea of this patient’s CHF; acute myocardial CHF.18 The increased airway pressure cre-
(difficulty breathing at night) and sitting infarction. The prehospital treatment of ated by CPAP actually pushes free fluid from
EMS1504S

the alveolar and interstitial spaces back into istered, evaluate the patient’s blood pressure and airway support with CPAP, as she is in
the pulmonary vasculature, correcting pul- after each administration, as hypotension moderate to severe distress and has no con-
monary edema and improving ventilation. is a possible and undesirable side effect. In traindications for the use of CPAP. Obtain
Patients in respiratory failure, as evidenced addition, question male patients about the IV access and administer 0.4 mg of nitro-
by inadequate respiratory rate or tidal vol- use of erectile dysfunction medications glycerin every 3–5 minutes while main-
ume, and patients in severe respiratory within the previous 24 hours, as concomi- taining a blood pressure of at least 90–100
distress with contraindications to CPAP mmHg systolic. Nitroglycerin administra-
should be intubated and ventilated with a tion will not only help treat the patient’s
BVM or placed on mechanical ventilation if
THE USE OF DIURETICS pulmonary edema but will also treat the
available. Positive end-expiratory pressure IN THE PREHOSPITAL active STEMI that caused it. As such, give
(PEEP) improves oxygenation and should TREATMENT OF the patient 324 mg of aspirin and transport
be administered to all intubated patients.11 her to a STEMI center. An IV diuretic such
Patients with heart failure and fluid vol-
HEART FAILURE IS AN as furosemide can also be administered to
ume overload will benefit from the admin- ONGOING DEBATE IN correct the fluid volume overload.
istration of a vasodilator such as nitroglyc- THE ACADEMIC
erin. Nitroglycerin added to diuretic therapy Case #3
may lead to even more rapid improvement
LITERATURE. You’re dispatched to a residential address
of pulmonary edema. 5,16 IV nitrates such for an unconscious person. Upon arrival you
as nitroglycerin or nesiritide are preferred tant nitroglycerin use can result in profound find a 72-year-old male slumped in a chair,
in the hospital environment but not typi- hypotension. unresponsive and in respiratory failure. The
cally available to prehospital care provid- Patients in LVHF are usually volume- patient’s wife says he got up out of bed last
ers. Sublingual nitroglycerin, while not as overloaded and require reduction of that night at about 2300 “because he was not
fast-acting or easy to titrate as IV, is an intravascular volume to reduce pulmonary feeling well and his breathing was bother-
effective means of achieving vasodilation. edema. Current guidelines recommend that ing him.” She awoke this morning about
Vasodilation is a benefit to the patient in patients with acute decompensated heart 10 minutes ago, found him as described
fluid volume overload, as it increases venous failure with evidence of volume overload, and promptly called 9-1-1. She says he
capacitance, reducing preload and decreas- regardless of etiology, be treated with intra- complained only of difficulty breathing.
ing net workload of the heart as well as venous diuretics as part of their initial man- He has a history of two myocardial infarc-
allowing for a fluid shift from the alveoli agement, level of evidence Class B (nitrates tions with three stent placements, CHF,
and interstitial lung space into the vascula- in this scenario are evidence Class A). 5,16 atrial fibrillation, hypertension and type
ture, especially when combined with CPAP. Excluded from this treatment are patients I diabetes. His medications include ASA,
While there are no national guidelines with hypotension or cardiogenic shock. nitroglycerin as needed, Lasix, diltiazem,
for the SL administration of nitroglycerin in Loop diuretics are the most common medi- dofetilide, Coumadin and insulin. He has
patients with CHF, we can consider the dos- cations administered in heart failure, and no known drug allergies.
ing guidelines for IV nitroglycerin and adapt common starting doses include:11 Your clinical exam reveals peripheral and
them to the prehospital environment and SL • Furosemide, 40 mg IV sacral edema, JVD, rales in all lung fields
administration. IV nitroglycerin is often • Bumetanide, 1 mg IV with little air movement bilaterally and cold,
administered at an initial dose of 5–10 mcg/ • Torsemide, 10–20 mg IV diaphoretic, cyanotic skin. His vital signs
min. and increased in increments of 5–10 The use of diuretics in the treatment of are: HR, 96/min. and irregular; BP, 70/palp.;
mcg/min. every 3–5 minutes as required and heart failure is an ongoing debate in the RR, 8/min. and shallow; SpO2, 68% on room
tolerated, with a maximum dose of about 200 academic literature, with many EMS medi- air. A 12-lead ECG reveals atrial fibrillation
mcg/min. A typical 400 mcg (0.4 mg) dose cal directors opting to remove the practice with a left bundle branch block and con-
of SL nitroglycerin used in the prehospital from their prehospital protocols. One recent cordant ST-segment depression in lead V3.
environment, administered every five min- study found that in the prehospital setting,
utes, would equal out to 80 mcg/min., well furosemide was frequently administered to Discussion
below the maximum dose considered for IV patients in whom its use was considered The patient in Case #3 is presenting in
nitroglycerin. In addition, the bioavailability inappropriate. In addition, it was “not decompensated cardiogenic shock with
of SL nitroglycerin will be decreased second- uncommonly” administered to patients in pulmonary edema and requires immedi-
ary to first-pass metabolism. clinical situations in which it was consid- ate intervention. The prehospital treatment
Patients with systolic blood pressures ered potentially harmful.12 As always, follow of the patient with cardiogenic shock and
greater than 150 can be administered 800 your local protocols. pulmonary edema centers on the follow-
mcg of nitroglycerin (2 x 0.4 mg doses) every Specific treatment for the patient in Case ing goals:
five minutes. Regardless of the dose admin- #2 would include oxygen administration • Ensuring airway patency;

• Ensuring adequate oxygenation and ventilation; aid in the understanding of the underlying problem
• Assessing for STEMI and monitoring the car- and treatment required. Regardless of the mechanism
diac rhythm; of HF, the treatment goals are similar for all patients:
ABOUT THE
• Gaining intravenous access, administering fluid • Ensuring airway patency;
AUTHORS
volume; • Ensuring adequate oxygenation and ventilation;
Scott R.
Snyder, • Correcting hypotension with inotropic or vaso- • Assessing for STEMI and monitoring the car-
BS, pressor medications. diac rhythm;
NREMT-P,
He is clearly in respiratory failure, and that and his • Gaining intravenous access;
is full-
time unconsciousness are contraindications for the use of • Correcting hypotension with inotropic or vaso-
faculty at CPAP. This patient requires immediate BLS airway pressor medications.
the Public Safety Training
maneuvers, the insertion of a BLS airway adjunct
Center in the Emergency REFERENCES
Care Program at Santa and BVM ventilation with 100% oxygen at 15 lpm in 1. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the
Rosa Junior College, CA. preparation for endotracheal intubation. The positive management of heart failure: executive summary: a report of the American
He is also a paramedic College of Cardiology Foundation/American Heart Association Task Force on
pressure generated via BVM ventilation, with a PEEP practice guidelines. Circ, 2013; 128(16): 1,810.
with AMR: Sonoma Life
Support in Santa Rosa, valve attached, has the same effect as CPAP with 2. Djousse L, Driver JA, Gaziano JM. Relation between modifable lifestyle
CA. E-mail scottrsnyder@ regard to driving fluid from the alveoli and intersti- factors and lifetime risk of heart failure. JAMA, 2009; 302: 394–400.
me.com. 3. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke
tial lung space back into the pulmonary vasculature. statistics–2013 update: a report from the American Heart Association. Circ,
Sean M. 2013; 127: e6–245.
The administration of nitroglycerin is not an
Kivlehan,
option in this patient because of his profound hypo- 4. Curtis LH, Whellan DJ, Hammill BG, et al. Incidence and prevalence of
MD, MPH, heart failure in elderly persons, 1994–2003. Arch Intern Med, 2008; 168:
NREMT-P, tension. This patient is having a pump problem and so 418–24.
is an 5. Roger VL, Weston SA, Redfeld MM, et al. Trends in heart failure incidence
should be administered IV fluid and an inotropic or
emer- and survival in a community-based population. JAMA, 2004; 292: 344–50.
gency vasopressor agent used to increase the blood pressure
6. Deaths: Final Data for 2012. Natl Vital Stat Rep, 63(9).
medicine resident at the and improve end-organ perfusion and mental status. 7. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence
University of California, of and survival with heart failure. N Engl J Med, 2002; 347: 1,397–402.
Dobutamine is frequently used to treat severe and
San Francisco. E-mail
refractory HF and cardiogenic shock,13 though it’s 8. Krumholz HM, Merrill AR, et al. Patterns of hospital performance in acute
sean.kivlehan@gmail. myocardial infarction and heart failure 30-day mortality and readmission.
com. not always available in the prehospital environment. Circ Cardiovasc Qual Outcomes, 2009; 2: 407–13.
Kevin T. Norepinephrine (Levophed) is a potent vasopressor 9. Joynt KE, Jha AK. Who has higher readmission rates for heart failure, and
Collopy, why? Implications for efforts to improve care using fnancial incentives. Circ
with some inotropic properties and if available can be Cardiovasc Qual Outcomes, 2011; 4: 53–9.
BA, FP-C,
CCEMT-P, considered in patients with severe cardiogenic shock. 10. Chun S, Tu JV, Wijeysundera HC, Austin PC, Wang X, Levy D, Lee DS.
NREMT-P, Dopamine, arguably the most common inotropic or Lifetime analysis of hospitalizations and survival of patients newly-admitted
WEMT, with heart failure. Circ Heart Fail, 2012; 5(4): 414–21.
vasopressor utilized in the prehospital environment, 11. Zile MR, Weller L, Gaash WH. Pathophysiology of diastolic heart failure.
is clinical
education coordinator can also be used. Dopamine, however, is not neces- www.uptodate.com/contents/pathophysiology-of-diastolic-heart-failure.
for VitaLink/AirLink in sarily “better” than dobutamine or norepinepherine. 12. He J, Ogden LG, et al. Risk factors for congestive heart failure in US men
Wilmington, NC, and and women: NHANES I epidemiologic follow-up study. Arch Intern Med.
While the efficacy of dopamine over norepinephrine 2001;161(7): 996.
a lead instructor for
Wilderness Medical is unclear, some evidence suggests that outcomes may 13. Colucci WS. Evaluation of the patient with heart failure or
cardiomyopathy. Up to Date, www.uptodate.com/contents/evaluation-of-
Associates. E-mail be better with norepinephrine.14 the-patient-with-heart-failure-or-cardiomyopathy.
ktcollopy@gmail.com.
Regardless of the vasopressor or inotropic agent 14. Klings ES. Cor Pulmonale. Up to Date, www.uptodate.com/contents/
used, titrate it to achieve a blood pressure that both cor-pulmonale.
15. Burns E. Right ventricular hypertrophy. Life in the Fast Lane, http://
ensures end-organ perfusion and creates a blood lifeinthefastlane.com/ecg-library/basics/right-ventricular-hypertrophy/.
pressure reserve. The emphasis in patients in car- 16. Overgaaerd CB. Džavik V. Inotropes and vasopressors. Review of
diogenic shock, from the EMS perspective, is ensuring physiology and clinical use in cardiovascular disease. Circ, 2008; 118:
1,047–56.
adequate ventilation and oxygenation, administer- 17. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA
ing vasopressors to ensure end-organ perfusion, and 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail, 2010;
16(6): e1.
rapid transport to a hospital for more definitive care.
18. Bauman KA, Hyzy RC. Noninvasive positive pressure ventilation in acute
respiratory failure in adults. Up to Date, www.uptodate.com/contents/
Conclusion noninvasive-positive-pressure-ventilation-in-acute-respiratory-failure-in-
adults.
Patients in heart failure can present on a wide clinical 19. 2013 ACCF/AHA guideline for the management of heart failure: a
and hemodynamic spectrum from seemingly minor report of the American College of Cardiology Foundation/American Heart
Association Task Force on practice guidelines.
complaints and stable vital signs to decompensated
20. Manaker S. Use of vasopressors and inotropes. Up to Date, www.
cariogenic shock. Recognition of the signs and symp- uptodate.com/contents/use-of-vasopressors-and-inotropes.
toms that accompany right- versus left-sided HF can 21. De Backer D, Biston P, et al. Comparison of dopamine and
norepinephrine in the treatment of shock. N Engl J Med, 2010; 362(9): 779.

ALTERNATIVE VEHICLES
Alternative Options for

Patient Transport
Specially designed ATVs and UTVs for EMS use enable EMS
providers to get to patients virtually anywhere
By Jason Busch, Associate Editor
A
mbulances are synonymous Those are times when alternative vehicles Real-World Applications
with EMS, but what happens like ATVs and UTVs become vital pieces After the events of September 11, 2001,
when patients are located of equipment, more than justifying their many EMS agencies began building on the
someplace an ambulance can’t expense. And while they may be small, ATVs observed successes of the use of ATVs and
go—a heavily wooded hiking used in EMS are still outfitted with much of UTVs by FDNY EMS during its response to
trail, a crowded urban area in the midst of a the same equipment as a standard ambu- the World Trade Center attacks, says Henry
major outdoor sporting event, a community lance, meaning quality patient care doesn’t Cortacans, MAS, CEM, NREMT-P, state
devastated by a natural disaster? need to be sacrificed for the sake of mobility. planner for the New Jersey EMS Task Force.
A rail exercise in Mercer County.

Henry Cortacans

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A New Hanover Regional Medical Center

EMS ATV.
Once the New Jersey EMS Task Force was

formalized in 2004—through the Homeland
Security grant program—it began building
its capacity. To date, says Cortacans, the
New Jersey EMS Task Force has more than
30 such assets in a fleet of more than 100
pieces of apparatus.
“These assets are utilized for many types
of special events,” Cortacans says, including
concerts, marathons, community festivals,
military air shows and more. “Because they
can quickly maneuver through large crowds
and tight spaces, it makes them ideal for
Lifelong Learning and these types of events.”
Community Engagement
Specifically, the New Jersey EMS Task
online.uwosh.edu/ferm Force has utilized its ATVs during the New
Jersey Marathon, Ironman Triathlon, Joint
Base Air Show and Super Bowl XLVIII.
ATVs are used for much the same pur-
pose in Wilmington, NC, where Aaron

Kasulis, EMT-P, EMS manager/battalion deposited in many portions of New Jersey. Fitting Into the Fleet
chief for New Hanover Regional Medical “These assets assisted with transferring As ATVs and UTVs play a unique role in
Center, notes his agency has been using patients from disabled ambulances, actu- EMS, special considerations need to be
them for 15 years. ally responding on some 9-1-1 calls,” Cor- made when budgeting for the vehicles and
“We use them at mass gatherings—pre- tacans explains, “and there was an instance determining how to best make use of these
dominantly downtown events when roads where one was deployed to a highway to resources.
are blocked off, high school football games, help rescue individuals from stranded In the case of New Hanover Regional
Civil War reenactments, etc. Really, any- vehicles in the roadway.” Medical Center, Kasulis says a separate “cost
place where crowd size and geographic
terrain may make for limited access. The
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“We use these for responses as well,”
states Cortacans. “During Tropical Storm
Irene a ‘strike team’ of these assets was
9 cubic feet of fully
deployed to Paterson, NJ, to assist with the enclosed storage for
equipment and supplies
evacuation of a large apartment complex
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During Superstorm Sandy, these assets
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ALTERNATIVE VEHICLES
center” is established aside from their normal and a binding contract with the EMS agency
operation budget, allowing for separation of provides for the Gator plus a medic for the
A Vehicle to Fit Every
monies. New Hanover has two Gator ATVs, duration of the event.
a 2006 John Deere Med-Bed and 2014 John The New Jersey EMS Task Force presents
Need
Just as there are different ambulance
Deere XUV, as well as a Kimtek MEDLITE. a different case, as each ATV/UTV asset is
body types and interior designs to fit
For large events where there will be an EMS hosted by a member agency of the task force, the specific needs of EMS agencies
presence, event organizers are charged a says Cortacans. The asset is used locally as and their patient populations, EMS
small hourly fee to have the ATVs on site, appropriate for that agency. However, when ATVs and UTVs come in all shapes and
sizes, and from a wide array of manu-
facturers.
Two of those manufacturers,
Alternative Support Apparatus (ASAP)
and Kimtek, offer different takes to
suit very specific needs.
Kimtek’s MEDLITE Transport skid
APRIL 28, 2015 units are made for budget-minded
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THRIVE IN THE large UTV side-by-side chassis on

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search and rescue operations.
ASAP’s MedStat is an off-road
The rapid evolution into community paramedicine
ambulance that features a fully
and mobile integrated healthcare has been enclosed, all-aluminum patient com-
one of the most discussed issues in the partment that secures a full-size cot
and seating for up to two attendants
EMS arena. Attend this exclusive event
and a driver. The MedStat unit has
and hear from your peers as they three base models—the MS 100, MS
share real-life examples of successful 250 and MS 500—that range from
a basic entry-level product up to a
programs in action. Agenda includes fully loaded high-end version. Each
individual and panel discussions model comes with an extensive list of
covering: options that gives the customer the
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• Why We Need Reimbursement Reform that best fits their needs.
• How to Develop an MIH-CP Program
• Economic Sustainability for MIH-CP Programs Brought to you by:
a request to mobilize these assets is made,
• The Role of Data Metrics and Outcome they are assembled into a strike team or task
and
Measures force and deployed as necessary.
• MIH-CP Programs in Action In partnership with: New Jersey has ATVs from a number of
• How to Build Winning Relationships different manufacturers, notes Cortacans,
but “our most popular model is the ASAP
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Support Apparatus (ASAP). We purchase
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these through the available funds from the
Register before April 10 and save! Homeland Security grant program. In order
to purchase the asset through the rules of

sized items,” he explains. “The ASAPs come with
a stretcher. There’s room for an attendant in the
back and it’s fully enclosed so we can mitigate
against the effects of weather. Generally, these are
staffed by EMTs; however, we have had instances
of paramedics staffing the asset(s) during extreme
circumstances and with approval from the New
Jersey Department of Health.”
Kasulis concurs. “The Gators’ equipment
On the beaches of mirrors the ambulance’s—ALS jump bag, O2 ,
Monmouth County cardiac monitor, backboard, splints—and they
after Superstorm Sandy even include medications and emergency air-
performing search and way equipment.” Paramedics who meet New
rescue. Hanover’s “unrestricted” status are allowed to
Andrew Caruso work the Gator, but staff must first successfully
pass Gator training and achieve competency
the grant program, they have to be used on a regional basis, which before operating the vehicle.
is why they are under the umbrella of the state EMS task force.” Cortacans adds the vehicles are extremely beneficial for agencies.
“They offer us flexibility in offering enhanced EMS coverage for
Equipping and Stafng a ‘Mini Ambulance’ special events, and give us a capability to respond to disasters by
Cortacans says the New Jersey EMS Task Force treats its ATVs and allowing us to get there. We even had a cardiac arrest resuscitation
UTVs like mini ambulances. “They have almost everything you’d in one of them during a densely populated street festival early on
find in a regular ambulance, except in less quantity and smaller- when we only had a couple of the vehicles.”
600 Series
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For More Information Circle 39 on Reader Service Card For More Information Circle 60 on Reader Service Card

AMBULANCE DESIGN
Addressing Ambulance
New ambulance design & safety
standards will be in place by 2016—the
question is, what will they look like?
By Jason Busch, Associate Editor
T
he safety and design standards for ambu-
lances in the U.S. will soon be changing,
but while the new requirements are sup-
posed to be in place by 2016, the industry
has yet to reach consensus on just what
those standards will look like. This poses an interest-
ing problem for ambulance manufacturers, which will
need to abide by the new standards, and the office
of EMS in each individual state, which will need to
adopt one of two competing sets of requirements.
Since 1974, the KKK-A-1822 (A-F) purchasing speci-
fication—or “Triple K”—has served as the guideline by
which federal agencies and grant recipients purchase
ambulances. However, while a majority of states use
the Triple K specs, ambulance manufacturers and
their customers have raised concerns in recent years
about the need for safety requirements that just aren’t
addressed in the guidelines. As a result, the Triple K
standards are set to sunset at the end of this year and
the EMS industry will need to adopt new guidelines
beginning in 2016. to provide medical treatment and transportation of
What’s slowing that process down, however, are sick or injured people to appropriate medical facilities.
competing sets of standards on the table. Both the NFPA states the standard presents general require-
Commission on Accreditation of Ambulance Services ments for ambulance design and performance, along
(CAAS) and the National Fire Protection Association with standalone chapters for ambulance components,
(NFPA) have proposed new ambulance guidelines, including chassis, patient compartment, low-voltage
and each set of standards differs. electrical systems and warning devices, and line volt-
The NFPA’s standard, NFPA 1917, is based on the age electrical systems. NFPA 1917 also specifies pro-
organization’s standards for fire apparatus. According visions for test methods.
to the NFPA, it was developed with consideration of Published in 2012, NFPA 1917 immediately met
the Federal Specification KKK-A-1822 and NFPA 1901: with resistance from the EMS industry, which noted a
Standard for Automotive Fire Apparatus. NFPA 1917 number of requirements viewed as overly restrictive,
defines the minimum requirements for the design, including limits on design and speed.
performance and testing of new automotive ambu-
lances intended for use under emergency conditions Continued on page 51

Standards
THE TRIPLE K
STANDARDS
ARE SET TO
SUNSET AT
THE END OF
THIS YEAR.
Society of Automotive Engineers Releases Crash Safety Standards

When industry experts gathered in patient litters, litter-retention systems collisions. This practice is based on spe-
Nashville for EMS World Expo 2014 (see and patient restraints in frontal and side- cific dynamics of the ambulance patient
EMSWorld.com/12030641), among the impact collisions. Its purpose, the SAE compartment and doesn’t apply to other
topics of discussion was building ambu- says, is to provide litter manufacturers, vehicle applications or seating positions.
lances to meet new crash safety require- ambulance builders and users with test- J3026 accommodates seating systems
ments from the Society of Automotive ing procedures and acceptance criteria installed in multiple attitudes, including
Engineers (SAE). Those requirements, to ensure the patient litter, its retention side-facing, rear-facing and forward-fac-
released in July 2014, are aimed at creat- system and the patient restraint utilize ing. Its purpose is to ensure ambulance
ing safer patient compartments and work dynamic performance test methodolo- occupant seating and restraint systems
environments for EMS personnel. gies similar to those applied to other meet similar performance criteria as
According to Jim Green, project offi- vehicle seating and occupant restraint FMVSS 208 requires for seat-belted pas-
cer, Division of Safety Research, National systems. It includes descriptions of the sengers in light vehicles.
Institute for Occupational Safety and test setup, instrumentation, photograph- Additional work on these standards
Health (NIOSH), the overarching goals of ic/video coverage, test fixtures and per- remains underway, Green said. This
the effort to revise the ambulance crash formance metrics. includes:
safety standards were to: Released at the same time as J3027, • SAE J3057: Patient compartment
• Provide patient compartment occu- J3043 explains dynamic and static structural integrity standard, which
pants with the same level of crash pro- testing procedures for evaluating the will dynamically and statically test the
tection as passenger vehicles; integrity of equipment-mount devices modular body to improve a builder’s
• Work with end users to ensure designs or systems in a frontal or side crash. It is ability to design and test for roll
meet needs; intended to provide equipment manu- impact loading. Likely to be published
• Develop system-specific standards for facturers, ambulance builders and users in summer 2015;
publication to be referenced nationally with testing procedures and acceptance • SAE J3058: Cabinet and cabinet latch
or internationally in the near term; criteria to ensure mounting mechanisms integrity standard, which will ensure
• Incorporate changes into one or more meet the same performance criteria cabinets retain equipment using
bumper-to-bumper ambulance nation- across the industry. It allows manufactur- established crash pulses. Likely to be
al standards in the long term; and ers to conduct either dynamic testing or published in summer 2015;
• Most important, ensure all proposed static testing. • Interior surface delethalization involves
standards are based on actual test A third recommendation, J3026, speci- making impact surfaces less likely to
data. fies testing procedures to evaluate the injure the worker or patient; and
Among the new requirements is the integrity of ground ambulance occupant • EMS Worker Anthropometry
J3027 recommended practice that seating and restraint systems for workers Study, which will assess body sizes
describes testing procedures for evaluat- and civilians transported in the patient and shapes (620 human subjects
ing the integrity of ground ambulance compartment during frontal and side planned—480 completed so far).

AMBULANCE DESIGN
TABLE 1: COMPARING THE TRIPLE K, CAAS AND NFPA AMBULANCE STANDARDS

Requirement KKK-A-1822F CAAS GVS-2015
Access handrails Grab handle on the inside of each door or adjacent body Grab handle on the inside of each door and
structure recessed overhead grab rail are required
Access to patient Primary attendant seat positioned a minimum of 25” Primary attendant seat positioned a
from head of cot minimum of 25” from head of cot
AMD testing to verify compliance AMD tests 1–26 are required AMD tests 1–26 are required
Bulkhead/partition Bulkhead with latchable door Bulkhead with window required and sliding
door optional
Cabinet storage load Not specifed pending SAE requirements Not specifed pending SAE requirements
Chevrons Optional Purchaser to specify
CO monitor Testing per AMD 007 required Testing per AMD 007 required
Engine hour meter Optional Optional
Equipment stowage criteria Minimum 35 cubic feet of interior storage; all devices to Purchaser to specify stowage requirements
be fastened to manufacturers’ requirements
Floor loading height Maximum is 34” Maximum is 34”
Floor testing requirements AMD 20 foor defection test required to prove foor load AMD 20 foor defection test required to
capacity prove foor load capacity
Generator requirements Not specifed Not specifed
Ground lighting under vehicle Step wells to be illuminated Step wells to be illuminated
Litter fasteners and anchorages NIOSH/SAE J3027 may be required in Change #7 efective NIOSH/SAE J3027 standard required
July 2015
Main electrical printed circuit board Certifed to “Class 3 life support” standard Certifed to “Class 3 life support” standard
Mounting and retention of NIOSH/SAE J3043 may be required in Change #7 efective NIOSH/SAE J3043 standard required
equipment July 2015
Occupant payload calculations Weight calculated at 175 lbs. per person Weight calculated at 171 lbs. per person
Patient compartment seating NIOSH/SAE J3026 may be required in Change #7 efective NIOSH/SAE J3026 standard required
July 2015
Payload requirement Type II 1,500 lbs. before options; Type I/III 1,750 lbs. All types 1,300 lbs. minimum payload after
before options; Type I/III AD 2,250 lbs. before options all options
Refective striping 6”-14” orange refective stripe around body Purchaser to specify
Required door openings Rear and side doors required; minimum dimensions Rear and side doors required; minimum
provided dimensions provided
Seat belt warning “Fasten Seat Belt” label required “Fasten Seat Belt” label required
Suspension clearance angles Approach: 20 degrees; breakover: 10 degrees; departure: Approach: 20 degrees; breakover: 10 degrees;
10 degrees departure: 10 degrees
Tire pressure monitor Optional Optional
Vehicle type certifcation Proof of compliance and complete certifcation testing by Proof of compliance and complete
ISO-approved laboratory is required for each type certifcation testing by ISO-approved
laboratory is required for each type
Warning indicators Door ajar light Door ajar light
Warning lights KKK or NFPA confguration acceptable Purchaser to specify

Wire harness protective loom 300° F maximum rated 300° F maximum rated
Wiring SXL, GXL copper wiring or better SXL, GXL copper wiring or better

In response, CAAS, a not-for-profit ambulance
NFPA 1917 accreditation organization, came out with its own
set of standards, the CAAS Ground Vehicle Stan-
Interior or exterior grab handles on the cab and patient compartment at each
dard (GVS-2015). Developed by a coalition of indus-
step location
try groups from EMS and the fire service, the CAAS
Seat-to-cot dimension provided to allow for multiple cot positions guidelines identify the minimum requirements for
new EMS ground ambulances built on OEM chassis
Some AMD tests required and prepared for use as an ambulance. This standard
Bulkhead with optional window applies to new vehicles only and does not include:
• Military vehicles/combat support ambulances
Each cabinet to be labeled with maximum load • Wheelchair vans/transport vehicles
50% of rear required to have refective chevrons in specifc red-yellow/green color • Mass-casualty vehicles/ambulance buses
• Refurbished or remounted ambulances
Monitor required
• Fire apparatus
Required According to CAAS, the purpose of the CAAS
All equipment 3 lbs. or more to be mounted or stored in an enclosure or bracket GVS-2015 is to “best serve patients by providing
ground ambulances that are safe, nationally rec-
No maximum load height specifed ognized, properly constructed, easily maintained,
AMD 20 compliance not required, NFPA minimum foor load is lower and when professionally staffed and provisioned,
Detailed requirements included BOTH THE NFPA AND CAAS

Under body lighting required at all step/access points HAVE PLANNED REVISIONS
NIOSH/SAE J3027 may be required in 2016 edition TO THEIR STANDARDS
DURING 2015.
Certifed to “Class 2 commercial/industrial assembly” standard
NIOSH/SAE J3043 may be required in 2016 edition will function reliably in prehospital or other mobile
emergency medical service.”
Weight calculated at 175 lbs. per person Right now, there’s no easy resolution in sight. Both
the NFPA and CAAS have planned revisions to their
NIOSH/SAE J3026 may be required in 2016 edition
standards during 2015, and as of now neither plan
seems to have gained a foothold across the entire
Purchaser to set minimum payload
EMS industry.
But if one plan does gain universal acceptance, it’s
4” refective stripe covering minimum 25% of front and 50% of length
going to dramatically affect the way ambulances are
Two means of escape required; minimum size 30” x 24” designed for years to come. Right now ambulance
manufacturers can design and build to any stan-
Seat belt monitoring system required with visual and audible alarms in cab dard. But if there’s just one accepted standard going
and patient compartment forward, it’s going to make it easier and more cost
Approach: 10 degrees; breakover: 10 degrees; departure: 10 degrees effective for manufacturers to build vehicles. And it
very likely could mean new safety features on ambu-
Visual indicator or monitor required lances that better protect the lives of patients and
Manufacturer may self-certify with exception of generator installation which providers.
requires third-party testing REFERENCES
CAAS. Ground Vehicle Standard (GVS-2015), www.groundvehiclestandard.
org.
“DO NOT MOVE” light attached to open door, equipment rack not stowed, or
NASEMSO. Differences Between NFPA 1917 (8/29/12), KKK-F and ASTM,
attached device open deployed www.nasemso.org/Projects/AgencyAndVehicleLicensure/documents/
NFPAfnalcondensedcomparisons11-12.pdf.
NFPA zone lighting or KKK acceptable
NFPA. NFPA 1917: Standard for Automotive Ambulances,
194°F maximum rated www.nfpa.org/codes-and-standards/document-information-
pages?mode=code&code=1917.
TXL, SXL or GXL acceptable—strands other than copper permitted

EMERGENCY VEHICLES
Ambulance Manufacturer
Directory Leading ambulance manufacturers profle their
latest vehicle designs and equipment
1 Braun Industries
Website: www.BraunAmbulances.com Engine Type: Gas, diesel
Ambulance Type: Type I, II and III Chassis Type: Ford, Chevy, Spartan,
International, Freightliner, RAM, Sprinter
For over 40 years, Braun has been manufacturing custom, handcrafted

emergency vehicles that are “Built for Life.” The 2015 lineup includes the
Responder, Signature Series, Patriot, Super Chief, Chief XL, Liberty and
Express. Each ambulance features the quality, safety and innovation Braun is
known for, including their SolidBody Construction, EZ Glide Door and other
Braun exclusives. This year the ambulance manufacturer will also be unveiling a
new model!
Circle 42 on Reader Service Card
2 Crestline Coach Ltd.

Website: www.crestlinecoach.com Engine Type: Gas, diesel
Ambulance Type: Type I and III Chassis Type: Chevy, Ford
Since 1975 Crestline has paved the way with industry innovations, manufacturing
the safest and most advanced ambulances and emergency vehicles on the
road. Crestline works with you as a partner through consultation, design,
manufacturing and delivery. We’ve been meeting the needs of our customers
in over 30 countries around the world, delivering world-class ambulances and
specialty vehicles. Our formula for success, the Crestline Advantage, consists of
three key values we excel at: safety, innovation and durability.
2
3 Demers
Website: www.demers-ambulances.com Engine Type: Diesel, gas
Ambulance Type: Type I, II, III and Chassis Type: Ford, Chevrolet, Dodge,
medium-duty Freightliner, International, Mercedes
Demers’ exclusive Mobility Track Seating keeps you safely strapped into a
comfortable, ergonomic captain’s seat that swivels and moves front to back and
laterally. Better access to critical equipment and controls means your patients
receive better care. The curbside seatback also folds down, providing support for
dual patient transport needs. Over 300 Demers vehicles across North America
are presently equipped with this feature, helping paramedics save lives.
3 Circle 44 on Reader Service Card

4 Lenco Armored Vehicles
Website: www.LencoArmor.com Engine Type: V-10 gas or V8 turbo diesel
Ambulance Type: Armored MedEvac Chassis Type: Ford F-550 Super Duty
The Lenco MedEvac was designed to meet the requirements of tactical EMS
personnel. It can be used as an armored response and rescue SWAT truck
for dangerous call-outs, and is equipped to provide tactical EMS with a safe
and effective environment to deal with trauma cases. The MedEvac has two
wall-mounted litters, two on-board jumbo-D oxygen tanks with a lighted work
station, and ample interior compartments for medical supply and gear storage.
4
5 Medix Specialty Vehicles, Inc.
Website: www.medixambulance.com Engine Type: Diesel, gas
Ambulance Type: Type I, II and III Chassis Type: Ford, Chevrolet, Mercedes
Medix has been manufacturing quality, affordable ambulances since 2000. Our
success centers around a robust structural design, excellent fit and finish, quality
of design, and consistently repeatable and managed manufacturing processes,
all with a focus on safety and dependability. Medix is the first ambulance
manufacturer certified to build on the Mercedes-Benz chassis and the first to
bring the new Ford Transit II to the market, and all Medix units are QVM and
KKK-A-1822 tested and compliant.
5
6 Mercedes-Benz USA/Daimler Vans USA
Website: www.sprintervansusa.com Engine Type: 2.1 L Bluetec 4-Cyl. CDI
Ambulance Type: Sprinter Cargo 2500 diesel; 3.0 L Bluetec V6 CDI diesel
for Type II and Sprinter 3500 cab-chassis Chassis Type: Mercedes-Benz and
Type III upfits Freightliner Sprinter cab chassis &
Sprinter 2500 cargo van
The Sprinter cab chassis offers efficiency, functionality and durability in one
complete package. The flat, unobstructed frame rails provide a variety of
upfitting opportunities and other features, such as standard high-output
alternator (V6: 220 amp; 4-cyl.: 200 amp and optional 250 amp); standard
adaptive ESP; optional high roof with tall rear and sliding doors; optional
auxiliary battery; and optional PSM with unique ambulance features like
wig-wag, high idle, idle shut down and continuous running engine feature.
Optional Ambulance Package available—please see your dealer for details
6 and availability.
ADDITIONAL MANUFACTURERS
American Emergency Vehicles Horton Emergency Vehicles McCoy Miller Road Rescue
www.aev.com www.hortonambulance.com www.mccoymiller.com www.roadrescue.com
Braun Northwest, Inc. Leader Emergency Vehicles Miller Coach Sartin Services
www.braunnorthwest.com www.leaderambulance.com millercoach.com www.sartinservices.com
Excellance, Inc. Life Line Emergency Vehicles Osage Taylor Made Ambulance
www.excellance.com www.lifelineambulance.com www.osageind.com www.taylormadeambulance.com
Frazer, Ltd. Marque Ambulance PL Custom Emergency Wheeled Coach Industries, Inc.
www.frazerbilt.com marqueambulance.com Vehicles www.wheeledcoach.com
www.plcustom.com

PRODUCT SHOWCASE
Dual-Vision XC Vehicle Cameras

Dual-vision XC vehicle cameras with post-route GPS
tracker, A/V and 160-plus hours of continuous recording.
DVXC continuously monitors and captures driving behavior
while simultaneously providing real-time driver feedback.
If predetermined speed limit and or G-force settings are
exceeded, drivers are notified with an audible chime. The
chime or “alert” is a behavior modification tool for drivers,
helping reinforce safe driving habits. DVXC continuous
video helps fleets confirm safe practices are consistently
maintained by drivers. Visit www.roscovision.com. Mac’s Bariatric Ambulance Lift
Circle 48 on Reader Service Card Mac's is Making Ambulance Crews Safer
with the Mac’s Bariatric Ambulance Lift.
With a 1,300 pound weight capacity the
lift is prepared for any job you can roll
on it. The platform is universal and will
accommodate whatever equipment you
choose to use. Bumper Stow Technology
makes the lift available to the ambulance
crew at all times, and functions as a
bumper and step. Don’t strain your back—
go see Mac! Visit www.macsliftgate.com.
Ziamatic Horizontal Oxygen

Cylinder Lift
Why risk back strain or injured feet when
exchanging medical oxygen cylinders?
Zico’s Horizontal Oxygen Cylinder Lift
Hassle-free Infant or Attendant Seat
This seamless attendant seat with three-
transports, raises and lowers “M” through
point belting system features a hassle-free
“J” cylinders so you don’t have to, keeping
latching system for attaching an infant
heavy cylinders secured through the entire
carrier to the popular EVS 1780 seat. This
exchange process. Rotates 90 degrees
seat will transport either the attendant
to facilitate horizontal loading into a
or uninjured infants. The infant carrier
compartment. Heavy-duty wheels allow
attaches to the seat in the same manner as Quantum ACR-4 Ambulance Child
for servicing of multiple ambulances with
a car. Simply latch in, tighten and go! What Restraint System
a single unit. Operates off of a supplied
are YOU doing to keep your passengers The ACR-4 (ambulance child restraint) is the
12v rechargeable battery; wall charger is
safe? Visit www.evsltd.com. latest version of the original ACR; however,
provided. Visit www.ziamatic.com.
Circle 49 on Reader Service Card ACR-4 now allows for the safe restraint
of all children from 4 pounds–99 pounds
during transport. The ACR-4 is an innovative,
RescueNet Road Safety Driving System
flexible and fully adjustable harnessing
Thousands of EMS vehicles in hundreds of agencies are equipped with Road Safety, the
system designed for the safe and effective
leading driver feedback and fleet monitoring system specifically
transport of infants and children in an
designed for the emergency response industry. By
ambulance, and it is color-coded for easy
proactively alarming and monitoring driver performance,
selection. Universal cot straps (included)
a comprehensive safety program can be implemented
connect with the ACR harness, holding
to ultimately create and reinforce a “Culture of Safety”
the patient in place to prevent potentially
throughout your organization resulting in improved safety,
dangerous movement during transportation.
reduced liability and lower maintenance costs. Visit www.
Visit www.quantum-ems.com.
zolldata.com/roadsafety.

Pioneer Series
With 10 different floor
plans available, the
Pioneer Series has
proven to be very
versatile for emergency
and quick response
units. Its user-friendly
compartments provide
readily accessible
MEDLITE Transport Units storage for all types of
Kimtek’s MEDLITE Transport compact equipment, all stored at
skid unit series is designed to be a cost- waist/chest height. Visit www.swabwagon.com.
effective, flexible solution for emergency Circle 56 on Reader Service Card
response in environments not suitable
for the traditional ambulance. These
lightweight slip-in skid units expand the
versatility of UTVs. The MEDLITE Transport
is ideal for use by all public safety agencies
and has applications on golf courses,
sporting events, industrial plants and
mines, and backcountry rescue. It is built
for off-road, rough, all-terrain and wildland
situations. It is a very effective way to put
the EMT right next to the patient during
transport. Visit www.kimtekresearch.com.
Narcotics Box for CompX eLock

New from CompX: the Narcotics Box for Custom Vehicle Equipment
CompX eLock is an access control device Kinequip manufactures and provides
for EMS vehicles. Made from seam-welded custom equipment for specialty vehicle
14-gauge steel with scratch-resistant applications. Products suited for the
powder-coated finish, the Narcotics rigors of activity on the open road
Box’s built-in 12V–9V converter allows for include LED lighting, digital temperature
dedicated power on board EMS vehicles. controls, custom switch panels, electronic
Features an auto-relocking door with interfaces, power distribution systems and
mechanical key override and full-length Ram mounting solutions for ambulances,
tamper-proof hinge (standard right-hand fire trucks, law enforcement vehicles,
door). Choose from factory installed school buses and other specialty vehicle
CompX eLock Wi-Fi, ethernet or non- types. Visit www.Kinequip.com.
network. Visit compx.com. Circle 58 on Reader Service Card
Engel EMS Refrigerator/Freezer Circle 57 on Reader Service Card
ENGEL USA offers a compact, constant-
temperature refrigerator/freezer, Power-LOAD Cot Fastener System
developed specifically for saline storage Power-LOAD helps reduce injuries when
for therapeutic hypothermic induction. loading and unloading. The Power-LOAD cot
The ENGEL EMS model features our “F” fastener system from Stryker EMS improves
series compressor, which is quieter and operator and patient safety by supporting
runs longer. It can store up to six saline IV the cot and patient throughout the loading
solutions and a small drug bag. Featuring and unloading process. By reducing spinal
a temperature range of 5°F to 113°F, it loads on operators, cumulative trauma
automatically heats in winter, and cools in injuries can be reduced. Power-LOAD
summer, to maintain the set temperature. wirelessly communicates with Power-
Visit www.engel-usa.com. PRO cots for maximum convenience and
Circle 55 on Reader Service Card efficiency. Visit ems.stryker.com.

ADVERTISER INDEX
COMPANY PAGE INQ # COMPANY PAGE INQ # COMPANY PAGE INQ #

American College of 56 61 Junkin Safety Appliance 47 39 Physio-Control Inc. 13 14
Emergency Physicians Co. Quantum EMS 16 19
Biotek Inc 47 60 Kimtek Corp. 45 38 Rosco Inc 44 36
Bound Tree Medical, LLC 5 12 Kinequip, Inc. 19 22 Simulaids Inc 40 33
Bound Tree Medical, LLC 29 26 Lenco Industries/SWAT 60 41 Stryker EMS 59 40
Braun Industries Inc 9 17 Trucks
SWAB Wagon Company, 39 32
CompX Security Products 35 28 Mac’s Lift Gate, Inc. 20 23 Inc.
Crestline Coach Ltd. 15 18 Mangar International 18 21 University of Wisconsin 44 37
Demers, Ambulance 11 16 Medix Specialty Vehicles, 17 20 Oshkosh
Manufacturer, Inc. Inc. World Trauma Symposium 31
Emergency Medical 38 31 Mercedes-Benz USA 3 11 Ziamatic Corporation 24 34
Products Miller Coach 25 25 ZOLL 2 10
EMS World EXPO 21 Minto Research and 37 30
EMS World National 27 Development Request Free Information at
Awards of Excellence Mobile Integrated 46 www.emsworld.com/e-inquiry
ENGEL USA 26 35 Healthcare Summit
EVS Ltd 34 27 NAEMT 10 15
Gerber Outerwear 7 13 Nasco 36 29
EMS Week 2015 To order your

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May 17–23 go to www.emsweek.org

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LIFE SUPPORT By Mike Rubin
EMS.O.S.
We need a secret way to ask for help—but what?
FOR YEARS I’VE BEEN TRYING TO JUSTIFY MY door. OK, so maybe I shouldn’t have referred to my
appreciation of the Three Stooges—mostly to The LIFEPAK 10 as “Old Sparky,” but hey, live and learn.
Lovely Helen, who claims the Stooges are proof the If we’re going to do this, we need to decide on the
alleged 5% difference between human and chimpanzee type of signal we’ll use. Consider these possibilities:
DNA is more like 4% in men. To my wife I say wake up • 10-codes—Almost every department has them or
and go to sleep. used to. The best thing about 10-codes is they’ll sound
“Getting” the Stooges is a Mars/Venus thing. On plausible to psychopaths.
behalf of my fellow Martians who happen to be in the The problem is consistency; there is none among
patient-processing business, I’ve figured out how to agencies. I’ve worked in systems where 10-1, 10-3,
make Moe, Larry and Curly almost as relevant to EMS 10-13 and 10-24 each meant help in the name of all that
as Johnny and Roy. But first some background: is holy, but 10-13 also might be the code for ordering
I’ve noticed discussions on EMS websites about a pepperoni pizza in some places.
the use of code words to request help in the field • Words—I’m thinking they should be part of routine
urgently and secretly. I can relate. I used to annoy transmissions—something like “Medic Rubin to Base,
my partners at Opryland with hypothetical scenarios show me back in service PUH-LEECE.” Or “Hospital X,
about sedate guests suddenly going postal. What if I’m inbound with a morderiske galning.” That’s Danish
a presenting lunatic insists I for homicidal maniac. Studies
treat him for an allergic reac- show very few sociopaths
tion to, say, gunpowder, then You could disguise speak Danish.
refuses the SWAT team AMA? your crisis code as a • Phrases—One approach
Am I supposed to look for an
opportunity to disarm him with
medical control option. would be to involve a signifi-
cant other, as in, “Hey, honey,
my penlight? “Sir, I just need just called to say how much I
to check your pupils for a few minutes—slowly, very enjoyed watching Real Housewives with you.” Helen
slowly, while you’re getting sleepy, so sleepy…” I don’t would know right away I was in trouble or suffering from
think so. a berry aneurysm. Either way she’d call 9-1-1.
A better solution would be a stealthy signal, known An alternative would be to keep it strictly business:
only by my agency, its members, their spouses and “Base, just wondering when that shipment of bretylium
Facebook friends, meaning help me right now or I will will be in.” Heh heh, got you there, Mr. Bad Guy…unless
haunt you for the rest of your life. Just put it in the back you happen to be one of my deranged ex-partners.
of the employee handbook under a heading that only • Protocols—You could disguise your crisis code as
ABOUT THE EMS people would look at—something like Photo of a medical control option. Medical control would figure
AUTHOR Human Eyeball Clawed by Rabid Chipmunk. out something’s wrong if you asked for, say, a chamo-
Look no further than the Three Stooges for a prec- mile infusion or a porridge challenge. I bet they’d send
edent. They had to deal with imminent badness in their help after they yanked your card.
1950 short Studio Stoops. • Nonverbal signals—How about keying S.O.S.
Moe and Larry are in a room, hiding from gangsters. through our radios? Oh, so Morse code isn’t part of
As Larry leaves he tells Moe, “When I come back, I’ll your curriculum? Fine, then just keep pressing PTT to
give you the password.” the beat of “Stayin’ Alive.”
Mike Rubin is a
paramedic in
“Brilliant. What’ll it be?” asks Moe. Cell phones might work if we could operate them
Nashville, TN, “Open the door.” like spies do in the movies—by feel, from a pocket. The
and a member That still cracks me up, but the idea of prearranged idea would be to discreetly send a canned text mes-
of the EMS
World editorial
words or phrases in EMS to limit danger is worth con- sage; something like “I’m being kidnapped by a patient
advisory board. sidering. I don’t remember being in a situation where who’s fondling my stethoscope.” Not sure about that
Contact him at I needed that, but I came close, twice, when patients one; Helen might think it’s just another overly dramatic
mgr22@prodigy.
net.
who told me they were ex-cons objected rather vigor- excuse for being late.
ously to being examined in a small room with a closed Nyuk, nyuk, nyuk.


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APRIL 2015 | VOL. 44, NO. 4 $7.00

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The Countdown to the 2015 Guidelines Has Begun.

Find out if your monitor is CPR

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© 2014 Mercedes-Benz USA, LLC

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The Thermal Angel® is a disposable, battery-powered blood

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22 Delivering ALS Care on the Fire Line

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Bobbie Merica continues her guide

VIDEO OF THE WEEK

talks to Chris EMS World

Colwell, MD, editorial advisory

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Protect your EMS practitioners and the patients they serve.

The NAEMT EMS Safety Course:

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Integrated Patient Transport System

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We’ve known it for years: Better, faster communication

Bottom line: Physio-Control solutions can help you

Bariatric Patient Care

THE LATE-AFTERNOON TRAINING session Initial Assessment

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Safest roll cage in the industry Crestline Advantage

www.crestlinecoach.com toll free (888) 887-6886

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The Quantum ACR-4 provides

3000 Marcus Avenue, Suite 3E6, Lake Success, NY 11042-1012

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Safe Patient Lifting

mangarint MangarLiftingCushionsUSA mangarusa.com

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MACS is Making Ambulance Crews Safer

Don’t Strain Your Back...

800-795-6227 sales@macsliftgate.com www.macsliftgate.com

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