STROKE Systems & Forensic Scientist at Fire-Rescue Med 2009
STROKE Systems Get stroke patients to the right hospital—fast In 1995, a major study backed by the National Institutes of Health confirmed that IV thrombolytics (or tPA) may have a positive effect on the outcomes of many victims of stroke, the third leading cause of death and number-one cause of adult disability in the U.S. But 13 years later, only an estimated 4% of eligible stroke patients in the U.S. are getting these "clotbusters." To improve that figure, the National Association of EMS Physicians advised in 2007: "EMS systems and medical directors should develop local/regional strategies for treating, triaging and transporting patients with acute stroke symptoms, including the identification of centers ... capable of treating acute stroke patients and [determining] the criteria for identifying the patients who should be transported to stroke centers." Now, many states are heeding that advice, creating statewide networks of stroke centers and training EMS practitioners to identify patients who need immediate transport to a stroke center. When the National Council of State EMS Medical Directors met in Tacoma, Wash., this fall, Utah’s medical director, Peter Taillac, MD, led a discussion on statewide stroke system development. Some states represented at the meeting have no stroke systems, and some have regionalized systems in only large urban areas. But just about every state seems to be working on some sort of plan. "For the past two years, Florida has required transport to one of 101 primary stroke centers or 11 comprehensive stroke centers," says Florida EMS Medical Director Joe Nelson, MD. Many Florida stroke patients are transported by air to cut down on time to definitive treatment, most to comprehensive stroke centers, including some airlifted "from the primary stroke centers to comprehensive stroke centers for additional treatment options," he says. Utah also uses a similar "hub-and-spoke" model with four comprehensive stroke centers at the hub and other hospitals acting as "stroke receiving centers." Physicians at a remote stroke receiving center "can consider starting tPA in consultation with a comprehensive stroke center," Taillac says. "The key is getting a CT scan performed and then interpreted by a radiologist or neurologist—perhaps via telemedicine." The CT scan is crucial to weed out the 15% of patients having hemorrhagic strokes because thrombolytics could prove fatal to such patients. It’s that fear that keeps many physicians from giving a clotbuster to any stroke patient. But a recent study of lawsuits related to stroke and thrombolytics found 83% of the settlements against physicians involved a failure to give a clotbuster and only 17% involved an injury from tPA (Liang BA, Zivin JA: "Empirical characteristics of litigation involving tissue plasminogen activator and ischemic stroke." Annals of Emergency Medicine. 52:160–4, 2008). "It is quite clear that the risk of withholding [thrombolytics] from patients with acute stroke greatly exceeds the risk of giving it," says Patrick Leyden, MD, director of the University of California, San Diego/Veterans Administration Stroke Center. "A well-run stroke center should be giving thrombolytics to 15–20% of all stroke patients." Time is of the essence in identifying and transporting stroke patients, because only patients with ischemic (or clot-based) strokes who have had symptoms for three hours or less currently get tPA in the U.S. But that window could widen. A significant new European study of 831 stroke patients found an IV thrombolytic "administered between three and 4.5 hours after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke." (Hacke W, Kaste M, Bluhmki E, et al: "Thrombolysis with Alteplase 3 to 4.5 hours after ischemic stroke." New England Journal of Medicine. 359:1314–1329, 2008.) "The implication is that now is the time to start diverting patients to [hospitals] with a system in place to rapidly treat stroke patients with tPA," Leyden says. "America has been behind the world in making this happen." —Mannie Garza See Noted Forensic Scientist at Fire-Rescue Med 2009 Dr. Henry Lee, a forensic scientist involved with many high-profile investigations, will be the sole presenter for an entire half-day at the International Association of Fire Chiefs’ (IAFC) EMS conference, Fire-Rescue Med, in Las Vegas in May. Lee, chief emeritus of the Connecticut State Police and founder and professor of the forensic science program at the University of New Haven, worked on investigations involving O.J. Simpson, JonBenet Ramsey, Laci Peterson, the 1993 suicide of White House Counsel Vincent Foster and the reinvestigation of President John F. Kennedy’s assassination. Lee is an expert in forensic science, forensic serology, blood-spatter analysis, crime scene investigation, crime scene profiling, crime scene reconstruction, fingerprints, imprints and general physical evidence. On May 6, the final day of Fire-Rescue Med, Lee will present two one-hour general sessions in the morning and will then answer questions at a special lunch session, which will be limited to 100 attendees. In the first session, "Lessons Learned from High-Profile Cases," Lee will talk about the problems, pitfalls and significance of high-profile case investigations. During the second, "Sharing My Life Experience," he’ll use stories from his experiences to "leave attendees with important lessons to think about when arriving on any scene." According to Lee, it’s important for first responders to be aware of their impact on crime scenes, particularly because the popularity of such shows as CSI has influenced how juries make their decisions. "Over the years, we’ve learned the scene gives evidence," he says. "Contamination of the scene may interfere with investigation and ultimately the outcome. First arrivals [should] learn how to correctly preserve and document [the scene] and, if necessary, collect evidence." At Fire-Rescue Med 2009, the IAFC EMS Section will offer two additional days of sessions by EMS leaders, plus two days of pre-conference seminars May 2–6 at The Orleans Hotel and Casino. For more information, go to www.iafc.org. —Ann-Marie Lindstrom Advisory Council Offers First Advice to NHTSA NHTSA created the National EMS Advisory Council (NEMSAC) this year to advise the agency on EMS concerns and got its first advice in October. The NEMSAC wants NHTSA to: > Ask the Federal Interagency Committee on EMS to urge the Centers for Medicare and Medicaid Services (CMS) to act on the Institute of Medicine recommendation to "convene a multidisciplinary ad hoc work group … to evaluate the reimbursement of EMS and make recommendations regarding inclusion of readiness costs and permitting payment without transport"; > Draft a document by the end of January outlining a vision for "an EMS culture of safety" to better protect patients and personnel and suggest strategies and action steps to make such a culture a reality; and >Work with other "federal partners" on a joint project to create national guidelines to help field providers determine the most appropriate mode of transport (e.g., ground, air, ALS, BLS) for a particular patient. "These issues are of such paramount importance to EMS as a whole that we had to take a stand," says NEMSAC Chair Dia Gainor, Idaho’s EMS director. NHTSA EMS Chief Drew Dawson enthusiastically accepted the NEMSAC suggestions. He committed to talking with CMS officials about the recommendation to form the ad hoc work group on reimbursement. He also said the recommendation to have NHTSA lead in creating an EMS culture of safety "is a great idea," and noted that a joint NHTSA/Centers for Disease Control and Prevention project on air-medical triage would be "the next logical phase in the CDC triage scheme." NEMSAC Finance Committee Chair Kurt Krumperman, MS, (Rural/Metro’s vice president for government affairs until Oct. 1, when he joined the faculty of University of Maryland, Baltimore County) says, "We proposed that NEMSAC work on developing an EMS cost-of-readiness model and the finance committee was tasked to do that." The finance committee will also conduct "a scientific literature review to see what has been done to demonstrate downstream health-care system cost savings that result from EMS interventions in the prehospital environment," he says. "This may help us strengthen the argument on the value of EMS." In late October, Gainor and Dawson invited 26 non-NEMSAC members to join the advisory council’s five committees. For a list of participants, visit www.jems.com. —MG New Members Join National Advisory Council Committees The National EMS Advisory Council added 20 new non-NEMSAC members to its five committees in November. NEMSAC Chair Dia Gainor appointed the new members based on recommendations from other NEMSAC members and "with the concurrence of the NHTSA Office of EMS." The new committee members are not Advisory Council members, but may participate in all NEMSAC meetings (as well as in committee meetings), although they can't vote on full-council recommendations and must pay their own expenses for attending those meetings. Here are the new committee members: (Committee chairs aren't new but are full NEMSAC members.) Safety (Jeff Lindsey, PhD, chair): Bruce Evans, North Las Vegas (Nev.) Fire Department; Daniel Patterson, PhD, University of Pittsburgh Medical Center; Nadine Levick, MD, Objective Safety; Ron Thackery, JD, American Medical Response; and Brian McGuire, PhD, University of Maryland, Baltimore County. Systems (Kyle Gorman, MBA, EMT-P, chair): Paul Sirbaugh, DO, Texas Children’s Hospital, Houston; Drexdal Pratt, North Carolina EMS director; and David Engler, Nebraska Professional Fire Fighters. Finance (Kurt Krumperman, MS, chair): Graham Nichol, MD, Harborview Medical Center, Seattle; Terry Mullins, Arizona EMS director; Troy Hagen, Ada County (Idaho) EMS; and Brenda Staffan, Rural/Metro Corp. Analysis, Oversight and Research (Ritu Sahni, MD, chair): Peter Dayan, MD, New York Presbyterian Hospital; Brooke Lerner, PhD, Medical College of Wisconsin; Dana Selover, MD, Oregon Patient Safety Commission; and Michael Schnyder, New Hampshire EMS data manager. Education and Workforce (Kevin Staley, MPA, chair): Carol Cunningham, MD, Ohio EMS medical director; John Becknell, publisher, Best Practices in Emergency Services; Steven Krug, MD, Chicago Children’s Hospital; and Gloria Murawsky Akuna, Milwaukee Fire Department. Gainor said the individuals "were chosen because of their demonstrated expertise in areas germane to committee work." She said, "They'll serve at a minimum through the rest of this NEMSAC term." That term lasts until January 2010. Although the committees meet primarily via teleconference, NEMSAC meets face to face four times a year, with the next meeting scheduled for January. For more information,visit www.ems.gov and click on NEMSAC on the pull-down menu under EMS System. PROBONO> Off-Duty Conduct: Only your business? If you post a picture of yourself using illegal substances on your public MySpace or Facebook page, can your EMS agency legally fire or discipline you? Probably—the law typically allows your agency to protect its professional reputation in the community. What if you’re "moonlighting," and your supervisor is concerned about how little sleep you’re getting? The agency could establish a policy requiring you to report to work well-rested, and could counsel or discipline you if there are objective signs you’re too tired to function safely. Many states also allow employers to limit moonlighting. EMS agencies have a legitimate interest to ensure you don’t pose a risk to yourself or others, especially while on a call. Employees often think their employer has no jurisdiction over their off-the-clock conduct. But EMS employers do generally have an interest in regulating certain off-duty behavior when there’s a legitimate work-related reason for doing so. And courts will typically allow such regulation when the activity puts the EMS agency in legal or financial jeopardy or may adversely affect its reputation or the safety of others. For example, employers have a legitimate interest in taking action against EMS staff for illegal off-duty behavior, especially if the conduct can affect job performance. Private employers generally have more leeway in disciplining employees for off-duty conduct. But municipal employers can regulate and even prohibit certain off-duty activities because there’s a legitimate interest in reducing fatigue, limiting litigation and lessening liability. The EMS employer should be extra careful when taking adverse action for off-duty conduct, and that action should be based on specific violations of department policy or "codes of conduct" whenever possible. Employees should make sure they’re fully aware of the rules and expectations of the employer and ask questions if they’re not sure what they mean. The key for EMS agencies to avoid problems is to set the expectations up front. Communicate the policy or code of conduct to everyone, and always follow the principles of "due process" and fairness before taking adverse action. 1. Ammon v. City of Coatesville, 1987 U.S. Dist. LE Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page , Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information. Quick Takes No More Diversions in Massachusetts Beginning in 2009, hospitals in Massachusetts won’t be allowed to turn away ambulances because their emergency departments are overcrowded. The Mass. Department of Public Health (MDPH) says ambulance services "may honor diversion requests" only when a hospital is closed to all patients due to an internal emergency. The MDPH advised hospitals to "adjust to this change" by examining their internal hospital systems to "ensure maximally efficient patient flow." Selling False Security For the past few years, many people have entered an in-case-of-emergency (ICE) number into their cell phones to allow emergency personnel to quickly reach a family member or friend. More recently, several vendors began marketing services that allow people to put their allergies, prescriptions, blood type and other such information on their cell phones. The problem: Most EMS responders don’t turn on patient cells to search for such information. "It’s not our practice to look on someone’s cell phone," Los Angeles Fire Department (LAFD) spokesman Capt. Armando Hogan recently told the Los Angeles Times. The LAFD cautioned on its Web site: "ICE is not something that paramedics rush to look for the instant they arrive at an emergency." Anthrax Meds by Mail If the U.S. suffers an anthrax attack, watch your mailbox for antibiotics. The Department of Health and Human Services (HHS) announced in October that local letter carriers could get kits with small amounts of antibiotics to protect themselves and their families against anthrax. These antibiotics would help protect letter carriers who volunteer to deliver antibiotics if "the Postal Service was called upon to deliver the same life-saving antibiotics directly to homes across their community where people may have been exposed to the bacterium that causes anthrax." HHS said the Postal Service has already pilot tested such a plan in Seattle, Philadelphia and Boston. Also in October, the federal Advisory Committee on Immunization Practices, which advises the Centers for Disease Control and Prevention, opened the door to voluntary anthrax vaccination for first responders, revising an eight-year-old recommendation against that step. NAEMT Has New Officers The National Association of EMTs installed new officers at its annual elections in Las Vegas Oct. 14: President Patrick F. Moore, President-Elect Connie Meyer, Treasurer Richard Ellis, Secretary Donald W. Walsh, and Immediate Past President Jerry Johnston. Serious gaming for your Computer A new computer game, "Zero Hour: America’s Medic," uses simulated mass-casualty scenarios in a virtual environment to prepare EMS responders for chemical, biological, radiological, nuclear and explosive (CBRNE) events. It focuses on CBRNE detection, triage and prehospital treatment, information collection and threat recognition, and information sharing and collaboration. The Department of Homeland Security (DHS) gave the National EMS Preparedness Initiative (NEMSPI) at George Washington University (GWU) in Washington, D.C., $1.2 million to create the game. According to Gregg Lord, associate director of the GWU Homeland Security Policy Institute, NEMSPI contracted with a private company, Virtual Heroes, to build the game and recruited EMTs, paramedics and first responders nationwide for the project’s steering committee. "I think this is a tremendous tool for people to learn what we’d want to know during a large-scale event. There are not a lot of chances to practice triage, so we have them ‘touch’ a lot of patients," Lord says. "Players must deal with chaos, panic, large volumes of patients and needs that far exceed available resources," the NEMSPI Web site states. "Each time EMS providers play the game, they’ll have different resources to work with, different scene hazards to deal with, different patients to treat and different resources they can call on." The game is designed to be completed in six hours (for six continuing education credits). Although Zero Hour is aimed at paramedics, it’s also appropriate for EMTs and first responders. "We decided to make it ALS and assume BLS providers would learn something along the way," Lord says. "We’re also getting a lot of interest from the gaming world, and we assume there will be a significant number of people paying for it initially who aren’t EMS providers." Anyone using a Windows platform can download the game for $14.95 at www.nemspi.com and play it as many times as they like. —MG
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