Endotracheal intubation (ETI) was a hot topic at the 2011 EMS Today Conference & Exposition in Baltimore March 1–5. A panel of experts debated every aspect of ETI, from how much training was enough to whether the endotracheal (ET) tube should be the go-to tool in the field.
“I personally am not convinced in our environment—EMS—that we should keep looking at the endotracheal tube as the gold standard,” Darren Braude, MD, MPH, FACEP, EMT-P, said during the panel. “Is it the best device under perfect circumstances to ventilate a patient and prevent aspiration? Yes. But in the real world, when was the last time I saved a life with an endotracheal tube?”
Braude says he’s a fan of ETI, but providers need to think about what’s best for the “patients and for the majority of providers. In most cases, the best device is good, basic maneuvers.”
Many paramedics in the audience at the panel session revealed how little experience they get performing this skill. The panel also discussed a study that suggests patients suffering from cardiac arrest fared better when not intubated.
Conversely, some diehards viewed the conversation as a challenge to their scope of practice.
“Why are we having this conversation at all?” asked Jullette Saussy, MD. “What’s the problem? Here’s the problem: It’s a skill; it requires motor memory; it requires education, and it requires practice.”
Getting practice is a challenge for many EMS organizations. Although some can go into local hospital operating rooms to practice on real patients, many are limited to manikins.
Criss Brainard, operations deputy chief for the San Diego Fire Rescue Department, says paramedics there average a relatively small number of in-service intubations. That said, with a good policy and a training regimen, they’ve had zero problems with intubations.
“I see us continuing to try to provide the gold standard airway and keep people proficient as we can,” Brainard says.
Another complicating issue is the flood of alternative options in the marketplace, such as supraglottic airways, which are easier to use. “Let’s not give them a reason to take it away,” says Brainard. “Let’s do our job, be the professionals we are and don’t give them any reasons to take it away.”
The debate raised some important questions.
“What I hear is we need to rethink our culture,” Saussy says. “We need to rethink how we manage the airway.”
She also said hospital staff need to change, too, and not make paramedics feel badly for not intubating when another option worked just as well.
“It’s EMS driving emergency department care,” Saussy says. “We’re the resuscitation experts.”
The intubation debate fell into a common theme throughout EMS Today: EMS responders should question conventional thinking.
Opening keynote speaker Brent Myers, MD, the medical director for the Wake County (N.C.) EMS System, says EMS is moving out of its “adolescence phase.”
“We as a house of medicine have treated EMS as a transportation agency for too long,” Myers told the packed ballroom. “We have the evidence to say ‘we are moving forward.’”
Moving forward into unknown territory may intimidate some, but David Page, MS, NREMT-P, reminded his session attendees that making mistakes is OK. “People who are clinical masters love their jobs, even when they make mistakes,” he says.
Another important message was presented by closing keynote speaker and JEMS columnist Steve Berry, who suggested EMS providers not be afraid to use humor in the field. He also reminded the audience it’s OK to laugh at things that people who aren’t involved in EMS might find morbid.
“We think from the brain,” Berry says. “We think from the gut, because sometimes we know this has to happen. But I also think we think from our heart. I think that’s truly the joy of EMS.”
The 2012 EMS Today Conference & Exposition will be held in Baltimore Feb. 28 through March 3.
—Richard Huff, NREMT
AHA Guidelines Clarifications
The December 2010 JEMS included an article that intended to summarize the 2010 American Heart Association Guidelines release. The article addressed key changes for BLS providers, laypersons and healthcare professionals, as well as key changes for ALS and post-resuscitation care for healthcare professionals. Following the article’s publication, several JEMS readers requested further clarification.
One of the most important changes is that untrained lay rescuers are now advised to provide “hands-only” CPR, also known as continuous chest compressions, for adult victims of sudden cardiac arrest (SCA).
An AED, ideally with a pediatric dose attenuator, may be used to treat infants if a manual defibrillator isn’t available.
Another area of emphasis is the importance of early recognition of SCA in adults based on assessing unresponsiveness and the absence of normal breathing. It’s important that citizens and providers recognize (and teach) what the Guidelines refer to as “the unusual presentation of SCA.” The Guidelines state that “victims of cardiac arrest may initially have gasping respirations or even appear to be having a seizure. These atypical presentations may confuse a rescuer, causing a delay in calling for help or beginning CPR.”
Dispatchers should be trained to recognize that SCA victims may exhibit “seizure-like activity or agonal gasps.” Dispatchers should intruct untrained lay rescuers to provide continuous chest compressions.
The chart below is meant to clarify the key Guidelines changes.
The Guidelines also present some important ALS changes that services need to address with their personnel:
- Providers should use quantitative waveform capnography for confirming and monitoring endotracheal tube placement. This is a new Class I recommendation for adult patients.
- Real-time monitoring and optimization of CPR is recommended.
- The use of adenosine and chronotopic agents for the diagnosis and treatment of certain heart rhythms is recommended.
- There’s an increased emphasis on identifying weak links in the Chain of Survival that account for variations in survival rates.
- There’s a reduced emphasis on mechanical devices and drugs. Atropine is no longer recommended for routine treatment of pulseless electrical activity and asystole.
- The routine use of cricoid pressure during airway management is no longer recommended.
- There’s an increased emphasis on the use of mild therapeutic hypothermia for comatose adult victims to improve neurological recovery. This is referenced in the Guidelines section on post-resuscitation care (the fifth link in the Chain of Survival).
EMS Today Debuts JEMSY Awards
This year’s EMS Today Conference & Exposition introduced a new program that allowed a panel of judges and conference attendees to view new products and vote on their favorites. Some of the product categories included Best New Product, Why Didn’t I Think of That? and It’s About Time! Awards were presented in the exhibit hall on Saturday, March 4.
The judges selected the Hurl-e “pocket-size” Emesis Container from Ramedic as the Best New Product winner. The Judges Choice winner was the Fastplint Vacuum Mattress by Hartwell Medical. And the Popular Choice award was given to Emergency Products + Research for its I.T.D. (improved traction device).
To learn more about the products that were submitted for the JEMSY awards, visit http://emstoday.com/en/Special-Events/new-products-program/.
New Therapeutic Hypothermia Device
“EMS is where we started,” says Cam Pollock, vice-president of global marketing for Physio-Control. With their mission still focused on prehospital resuscitation, Physio-Control continues to deliver innovative prehospital products.
In partnership with BeneChill, a medical device company in San Diego, Physio-Control has begun European distribution of the RhinoChill IntraNasal Cooling System. RhinoChill can initiate prehospital therapeutic hypothermia through the nasal cavity. The system uses a pressurized canister of an inert, highly volatile liquid that’s delivered through a nasal cannula. Because the nasal cavity is large, close to the brain and has a thin boundary with the brain, RhinoChill cools the brain faster than whole-body cooling schemes, such as cooled saline solution, ice packs or cooling blankets.
Small studies in Europe have shown significant differences between cardiac arrest patients who receive RhinoChill therapy in the field, compared with those who aren’t cooled until hospital admission. There have also been animal studies that show the system is promising.
Now that hospital-based cooling is so well established, Pollock says Physio-Control looked to providing reliable, effective prehospital options. He says they “looked at almost everybody using cooling” before partnering with BeneChill.
RhinoChill has just gone on the market in Europe. It will be a few years before it shows up in the U.S., if further studies and clinical use prove it delivers.
Reduced Heart Failure Hospitalizations
Prehospital care continues to evolve beyond responding to trauma and sudden illness. High-tech devices that provide improved monitoring of chronic conditions expand the very concept of prehospital care.
A tiny device, about the size of a paper clip, holds promise to reduce the number of hospitalizations—and it would follow EMS calls—for heart failure. According to American Heart Association statistics, nearly six million Americans suffer from heart failure.
“It’s very exciting. One more tool to reduce hospitalizations,” says Keith Wesley, MD, medical director for HealthEast Medical Transportation in St. Paul, Minn.
A six-month study of the wireless implantable hemodynamic monitoring (W-IHM) system, developed by medical device company CardioMEMS, showed 30% fewer heart-failure-related hospitalizations in the group of patients with the device compared with the control group.
The W-IHM system allowed daily measurement of pulmonary artery pressure. That information, combined with symptoms and clinical signs, improved heart-failure management.
The pressure sensor is implanted in the pulmonary artery through right-heart catheterization. An external reader uses radio-frequency communications to gather that data, which can be forwarded to the patient’s doctor.
The study was funded by the company that developed the device, so further studies are inevitable before FDA approval.
NAEMT Safety Course Debuts
The National Association of Emergency Medical Technicians (NAEMT) launched a new, one-day EMS Safety course at the 2011 EMS Today Conference & Exposition in Baltimore. It’s now in the process of rolling the program out nationwide. The eight-hour class covers vehicle safety, scene safety, bystander safety and personal health.
“It seems more people are getting hurt in this business than ever before,” says Glenn Luedtke, who headed the committee to design the class. “We decided to do something like this, something we can give people in the street and enlighten them. That’s the purpose of the course, to help people be safer at work.”
Luedtke was driven to work on the project because of his own experience at the Sussex County (Del.) Emergency Medical Services. In a short period of time, one medic was seriously hurt in a crash and another killed.
“I recognized in our little world we need to do something to keep these people safer,” he says. “It is the nature of the people who get into this business to think about people first. But the back of the ambulance is one of the most dangerous places to work in the world.”
NAEMT is now in the process of scheduling other sessions around the country and increasing the number of instructors. At EMS Today, Luedtke received the Nicholas Rosecrans Award, which honors leadership in injury prevention.
“A lot of it is about communication and avoiding errors,” Luedtke says of the class. “If we can avoid errors, we can reduce accidents.”
In the fire service, one of the worst things that can happen is putting out the fire completely and getting called back for a “rekindle” a few hours later. It’s an embarrassment, and the property can be destroyed. When the same scenario happens in EMS—leaving a patient behind and getting called back later—the consequences are far worse. Instead of embarrassment and property damage, a “medical rekindle” may lead to tragedy: death or disability for the patient, and lawsuits for EMS providers and their organization.
We’ve seen an increasing number of headlines in which EMS has been called back to find a critical patient after that same EMS agency had just recently seen the patient and left the scene. Headlines such as “Man Declared Twice in Four Days” or “Life Goes on in the Body Bag” are headlines you simply don’t want to see. How does this happen? Could it be apathy, inadequate patient care skills, reckless disregard for the patient or just plain laziness? There are many factors that come into play. Bottom line: We should never have to return to find a living patient after we’ve “declared them dead.” It’s simply unacceptable.
Abandoning a patient is one of the biggest liability areas for EMS agencies. In addition to the harm to the patient, there have been very high money awards (in the millions of dollars) with some of these “left for dead” cases. This type of catastrophe can seriously damage the public’s confidence in us and destroy organizational and individual reputations. Here are some tips to avoid the flames of a medical rekindle:
1. Treat every call like your first call: Be upbeat and ready to serve the patient with the highest level of compassion and skill we can muster.
2. Be well rested and on your game: Don’t “short shrift” patients because you aren’t adhering to your professional obligation of being prepared. Remember, patients aren’t an inconvenience; they’re the reason we do what we do.
3. Carry all your equipment to the scene: Don’t just carry the clipboard with you. Bring all the resuscitation equipment with you to the patient’s side. You can always bring it back to the truck if you determine you don’t need it.
4. Don’t rely on what others say: Although these scenes can be chaotic, don’t accept conclusions from others on scene. Do your own assessment, fully and completely.
5. They’re not dead until they’re wired and dead: Conduct a complete and objective assessment. Don’t second guess what you think may be wrong, and don’t let your biases influence your judgment. No patient should be declared dead or left for the coroner until an ECG strip has been run to verify lack of cardiac electrical activity.
6. Keep your eyes open and look around: Consider things that could “mimic death” and lower metabolism, such as hypothermia or certain drug interactions.
7. Follow your protocols: Increasingly, your treatment protocols will be the standard by which you’ll be judged in court. Ensure you follow them to the letter or have a good and documented reason that you didn’t—especially in high-risk situations, such as leaving a patient behind.
8. Everyone is a potential patient: Just because you aren’t directly at the patient’s side doesn’t mean there isn’t a patient in your midst. The defense that “we didn’t have patient contact” is a weak defense when you’re the medical professional called to the scene to assess the situation in the first place.
9. Be assertive: Don’t be bullied by police, bystanders or other responders. Yes, it may be a crime scene, but you still have the obligation to reach the patient and assess for signs of life.
10. Imagine your patient is your loved one: You’d be horrified if you learned that your loved one was left behind, not properly assessed or otherwise “left for dead.” The public has a fundamental expectation that we’ll be competent, caring and compassionate care givers. They expect to be treated just as we we’d want our own loved ones to be treated. That means we respect all human life and strive to protect and preserve life wherever possible and without question or hesitancy.
We need to go that extra step, if necessary, to ensure the patient is indeed beyond resuscitation. To do anything less is not doing our job as a professional prehospital caregiver.
Steve Wirth, Esq. and Douglas Wolfberg, Esq. also share what not to do on Facebook:
1. Don’t post inappropriate pictures of yourself or others;
2. Don’t post pictures or make comments about patients;
3. Don’t complain about your Job, supervisors or coworkers;
4. Don’t post conflicting information about your credentials or résumé;
5. Don’t lie about your profile information or lie in your postings;
6. Don’t post statuses you wouldn’t want your boss to see;
7. Understand and check your
8. Don’t accept or “troll” for “friends” who aren’t really friends;
9. Don’t post things while engaged in work activities;
10. Don’t make statements about others that can lead to defamation or slander claims;
11. Don’t violate copyright laws or misuse other peoples’ stuff;
12. Don’t share confidential or proprietary information;
13. Don’t “trash talk,” pick fights or harass others;
14. Avoid politically charged statements or statements that indicate “biases;” and
15. Correct your mistakes! JEMS
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 website at www.pwwemslaw.com for more EMS law information.
In Brief: For more on what you missed at EMS Today, visit www.emstoday.com.
New free EMS response to civil unrest program: www.ffsupportorg.
Register for Fitch & Associates ambulance service manager program http://creative.epsinternet.com/apps/rurl/zX4WtL5H1.
National EMS Memorial Service announces 2011 Moment of Silence: http://nemsms.org/silence.htm.
This article originally appeared in April 2011 JEMS as “2011 EMS Today: What you missed.”