On Oct. 5, the Wake County EMS System inRaleigh,N.C., began prehospital induction of hypothermia for victims of cardiac arrest who are non-neurologically intact after return of spontaneous circulation (ROSC).
During the preceding six months, representatives fromEMS joined with partners from receiving hospitals to form an induced hypothermia task force. Participants included paramedics, emergency department and critical care nurses, and physicians representingEMS, emergency medicine, cardiology and intensive care. This group developed protocols promoting coordinated care that begins in the field, continues in the emergency department and is completed in the ICU.
The task force concluded that commercially available cooling products could not be placed aboard the nearly 50 ambulances in ourEMS system due to fiscal constraints and lack of sufficient space on the ambulances. After reviewing previously published protocols, the group chose to use ice packs and the infusion of chilled saline as the prehospital tools for induction.
To avoid shivering and provide for patient comfort, sedation and paralysis are also components of the prehospital care. Because the Wake County EMS System does not utilize rapid sequence induction for intubation, hypothermia is provided only for those patients intubated in the regular course of their cardiac arrest care.
The greatest technical challenge during implementation was how to keep the saline at the target temperature (1Ï2_ C). Testing revealed that coolers and commercially available refrigerators did not keep the saline sufficiently cool and that placing the bags in a full-size, station-based freezer prior to deployment created ice blocks that would not thaw with sufficient speed. After many trials, one chilling device, the Engle Model 15, was found to perform well. Bags of saline are chilled in refrigerators at the station prior to placement in the device, after which the fluid is cooled further and maintained within the target temperature range.
Because of the coordination established during the task force meetings, we believe the transition of care from the prehospital to the in-hospital phase will be seamless. We hope this brief concept article will assist other communities considering implementation of prehospital induced hypothermia.
Stayin_ Alive & Compliant
The American Heart Association (AHA) changed its CPR guidelines in 2005 to increase the chest compression rate to 100 compressions per minute (CPM). But many responders have yet to grasp just how fast that is, according to Alson S. Inaba, MD, a national AHA faculty member for PALS and a member of the AHA Program Administration Subcommittee.
˙The most common error is to push too fast,Ó says Inaba, a pediatric emergency physician atKapiolaniMedicalCenter for Women and Children inHonolulu. When he asks CPR class members to demonstrate 100 CPM on a manikin, they usually deliver 120Ï150 CPM, which is too fast to allow the chest to fully recoilƒanother new AHA recommendation.
Then one day Inaba was listening to a recording of the 1970s disco hit ˙Stayin_ AliveÓ when he had a hunch. He timed the song_s rhythmƒexactly 100 beats per minute.
Now, he has students clap the beat as they listen to the song and has one student deliver chest compressions to that beat while another student counts the number of compressions delivered in one minute. They invariably come up with 99, 100 or 101 CPM, Inaba reports.
˙Most people know the tune, and it sticks with them,Ó he says. He uses it in all his classes and shared it with other CPR instructors at the AHA Emergency Cardiovascular Care Update Conference in June.
˙Once you get the beat, you can hum it while you do CPR,Ó Inaba says. But hum quietly, he warns. ˙When I first started teaching this, a respiratory therapist brought in some residents to help with a resuscitation and he was humming rather loudly to keep them doing [correct] compressions, but the family didn_t know what they were doing.Ó
According to Inaba, ˙Hollywood couldn_t have written a better script: ÂStaying alive_ describes the AHA mission and reminds us what we_re trying to achieve with chest compressions, and the song was No. 1 on the charts in 1979 when AEDs first came out.Ó
For another tip from Inaba, visitwww.jems.com/tips. ƒMannie Garza
Cardiac Death inWaiting Room a Crime
A coroner_s jury in Illinois recently ruled that the death of a woman who died of a heart attack while waiting two hours in an emergency department (ED) waiting room with the classic signs of a myocardial infarction was a homicide. The jury said Beatrice Vance, 49, died ˙as a result of gross deviations from the standard of care that a reasonable person would have exercised in this situation.Ó
Vance reportedly arrived atVistaEastMedicalCenter inWaukegan complaining of nausea, shortness of breath and chest pain that she rated at ˙10Ó on a scale of one to 10, but a triage nurse listed her condition as ˙semi-emergent,Ó Lake County Coroner Robert Barrett said during a Sept. 14 inquest. After sitting for two hours with no attention, Vance was found unconscious and without a pulse and failed to respond to CPR. (The hospital did not respond to requests for comments.)
Although Vance_s symptoms apparently didn_t get immediate attention, the verdict has garnered national interest. On Sept. 19, theAmericanCollege of Emergency Physicians (ACEP) issued a statement urging the public that patients in ED waiting rooms should ˙notify the triage nurse if they are in pain or if they start to feel worse. If they are still concerned, they should ask to speak to an emergency physician or a patient advocate.Ó ACEP also warned that ˙criminalizingÓ the efforts of ED staff ˙would be a terrible mistake and have a chilling effect on people going into the medical field.Ó
ForEMS, it_s a reminder why the public should be instructed to call 9-1-1 for such symptoms as chest pain and shortness of breath. Not only will they have EMTs or paramedics with them if their symptoms worsen, but ˙patients are triaged much higher when they come in viaEMS,Ó observes Winnie Maggiore, JD, NREMT-P.
˙But the most important message from this case is that the legal system is willing to cross the line from civil negligence to criminal liability when a patient has to wait too long,Ó Maggiore says. ƒMG
Ready or ÂReallyReady_?
When Emily Hesaltine took an internship at the Federation of American Scientists (FAS) between her sophomore and junior years in college, she imagined she_d spend her summer stapling and making copies. The University ofVirginia student with a double major in systems engineering and economics never dreamed she_d be on ABC News by August as a result of a new Web site she created.
This summer, Hesaltine carefully reviewedwww.Ready.gov, the Department of Homeland Security (DHS) Web site designed to help the public prepare for disasters. She discovered inaccuracies, contradictions, misleading statements, redundant information, and confusing design and information presentation. So Hesaltine created www.ReallyReady.org, a Web site similar to the DHS site but much improved, according to FAS.
One example: Hesaltine found that Ready.gov advice on face masks for nose and mouth protection runs 227 words in four paragraphs. On ReallyReady.org, she presents the relevant information in 87 words, organized into five easy-to-digest bullet points.
FAS Director of Biology Policy Michael Stebbins, PhD, who supervised Hesaltine, had done some preliminary analysis on Ready.gov and warned Hesaltine of what she was getting herself into. But she was thrilled to have a useful independent project. ˙I didn_t even consider the implications,Ó she says.
Besides catching the interest of national news organizations, Hesaltine_s project has also attracted attention from DHS, which claims FAS is infringing on DHS_s intellectual property rights by using graphics similar to those on Ready.gov. But Stebbins says he hopes ˙to bring the discussion above petty argumentsÓ and that DHS will ˙request the assistance of scientific, military and emergency response experts to make crucial alterations to Ready.gov.Ó ƒAnn-Marie Lindstrom
Meeting of the Minds
On Oct. 16-17, the first National EMS Preparedness Initiative (NEMSPI)Summit was held inWashington,D.C. By invitation only, 50 chiefs, administrators and directors of EMS operations fromAmerica's largest cities attended the summit, which served as their first-ever opportunity to collectively discuss issues regarding theEMS role in protection, preparedness, response and recovery to large-scale events.
Funded by the U.S. Department of Homeland Security grant to The George Washington University Office of Homeland Security, the initiative focuses on street-level providers. ˙This is about the more than 900,000 EMTs and paramedics onAmerica's front-lines charged with the awesome responsibility of turning victims into patients,Ó says Frank Cilluffo, HSPI director and associate vice president of GWU. ˙We want to make sure emergency personnel have the tools they need.Ó
The second summit, to be held in spring 2007, will also include industry leaders, representatives of constituency organizations, and state and federal officials from various departments who have an active role inEMS response. For more on NEMSPI, visitwww.nationalemspreparedness.org.
HOSPITAL DESTINATIONS: Who Calls the Shots?
Some EMS systems consider it a bedrock principle that competent patients can choose the particular hospital to which they wish to be transported, and manyEMS providers believe they would be violating the law if they were to transport a patient to another destination. But does the law ever allow EMS crews to transport a patient who is legally and mentally able to make health-care decisions to a hospital other than the one that patient requests? Generally, it does (subject, of course, to individual state laws, regulations andEMS system protocols).
Although health-care providers generally must follow the expressed wishes of a competent patient (or the patient_s legal proxy) whenever those wishes are expressed as the result of an informed decision-making process, this principle has its limitations. When you think about it, it must.
Take, for instance, a patient who insists on being transported to a hospital 30 miles outside your service area when an appropriate facility is just five miles away and within your coverage area. Now suppose that your organization only operates one or two ambulances. Nothing in the law necessarily requires an ambulance service or fire department to commit its resources for an extra hour or so to accommodate a specific destination request at the expense of leaving an entire community uncovered or underserved.
EMS services would be wise to have a written and carefully considered patient-destination policy that addresses confusing issues (including hospital diversions), tax resources and liability concerns. Such a policy should be consistent with any applicable patient-destination protocols that exist in the largerEMS system, but such a policy at the ambulance-service level can prevent problems and promote consistent decision-making within your organization.
This tip is provided by Page, Wolfberg & Wirth LLC, a national EMS, ambulance and medical transportation industry law firm, and written by attorneys Doug Wolfberg and Steve Wirth, both of whom have extensive EMS field and management experience. Check out the recently relaunched PWW Web site,www.pwwemslaw.com, and its extensive EMS law library.
Names in the News
The new NAEMT PresidentJerry Johnston,NREMT-P, is the EMS director at Henry County Health Center in Mt. Pleasant, Iowa, a countywide all-ALS system. He also manages a BLS/ALS/critical care transport service in Burlington, Iowa. A second-generation EMS provider, he began his career in 1975 and is a past president of the Iowa EMS Association. He has also instructed all levels of EMS providers, taught ACLS and PALS, is a past BLS national faculty member for the AHA and served as the first chair of NAEMT's Pediatric Prehospital Care Executive Council.
Other new officers are President-ElectPatrick F. Moore;Vice PresidentConnie Meyer; TreasurerEdward J. Sawicki;SecretaryRobert A. Loftus;and directorsAugie Bamonti;Will Chapleau;Richard Ellis;Jennifer Frenette;andJim Slattery.Ken Bouvierbecame the association's immediate past president.
During the conference, NAEMT also presented numerous awards. Among them,Sedley A. Tomlinson,NREMT-B, received the Robert E. Motley EMT of the Year award, sponsored byJEMSTonia L. Hale,NREMT-P, was named the Asmund S. Laerdal Award for Excellence Paramedic of the Year, sponsored by Laerdal;Jeffrey D. Dumermuth,EMT-P, won the Moore-Medical sponsored William Klingensmith EMS Administrator of the Year award;Jonathan Brent Meyers, MD,was named EMS Medical Director of the Year, a Ferno-Washington sponsored award;Gary W. Odom,NREMT-P, received the Mary Ann Talley EMS Instructor/Coordinator of the Year award, sponsored by Mosby; NHTSA EMS ChiefDrew Dawson,won the National Registry of EMTs Rocco V. Morando Lifetime Achievement Award;Ellinwood (Kan.) EMS, was named the Leo R. Schwartz Emergency Medical Service of the Year, sponsored byEMS Magazine;andAmerican Medical Response, El Paso County, Colo., won the EMT-Paramedic Emergency Medical Service of the Year award, sponsored by ZOLL Medical Corp.
Also, NAEMT members voted Sept. 27 to change the bylaws to allow first responders (as well as EMTs and paramedics) to become full voting members and to allow members more voice in the election of officers. For more on these changes, visitwww.naemt.org. ƒMG