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EMS Today Unplugged

Allow me to introduce you to the world of the big-time EMS speaker. You re sitting happily at home one day when you receive a phone call or e-mail asking if you would like to present at a conference. You find out when the conference is, tell them you d be happy to do so and ask what they want you to talk about. They ask what you have available. You tell them, and a week or two later they tell you what they wanted in the first place. You agree.

Getting ready

Several months later, you re sent a packet of documents asking for lecture outlines, objectives, disclosures and things to put in the syllabus. You immediately misplace them. A month before the meeting, you re asked to arrange your travel, which you also promptly forget to do.

With a week to go, you finally go to the library to pull a few articles, only to find that the journal you really need is archived somewhere in Croatia. In an effort to add some kind of substance to your talk, you stay awake for two straight nights pulling things off the Internet only to find you ve actually spent most of your time trying to break 1,200 points in Spider Solitaire. Once they let the tray tables down on the flight to your destination, you begin to write the lecture, always making sure there s just enough on the slide to remind you of two minutes of material when you flash it on the screen.

(There is apparently one other step in the process that I have not yet mastered. A friend who has put together several conferences told me that when he contacts speakers, they always ask him who else has spoken at previous meetings. I guess the theory here is if nobody famous has been there first, you re too famous to follow. As for me, I like my periodic forays into the majors, but mostly I m pretty happy in the bush league.)

Let the games begin

Because your sponsors have footed the bill for your airfare and hotel, they own you. At least I think they do, which is why I m always a pretty good deal for a conference. I fly cattle class, don t list stamps and postcards as expenses and pretty much do whatever I m told. That s why when JEMS Editor A.J. Heightman, the Baron de Coubertin of prehospital care, asked me to help judge the 2004 JEMS Games at the EMS Today Conference in Salt Lake City, during the first week of March, I didn t consider it a request.

If you ve never been to an EMS competition, it s well worth the time. Firefighter and police competitions are often based on tests of fitness and physical agility. EMS competitions are a whole different ball game. There are some physical challenges, but situational awareness, mental acuity and teamwork are the keys.

The 2004 JEMS Games are the first of what will hopefully be an annual competition of the world s best EMS squads.

The way these competitions work is that the judging team establishes a scenario for care, building in a number of tough clinical calls, triage decisions and technical challenges. Points are assigned for each task accomplished, and certain critical actions may markedly enhance one s score. Similarly, actions not taken may prohibit further scoring. Teams are composed of three members and an alternate. Team members may divide tasks between them in whatever manner they see fit.

The only drawback to watching an EMS competition is that because EMS teams work in tight quarters and are surrounded by judges, it can often be difficult to see exactly what s going on. Some competitions use video feeds to allow all spectators to watch the contestants work on the big screen. Honestly, the best way to see an ALS competition is to participate in one, either as a contestant or as a judge. (I ve always wanted to be a competitor just to see how I d do, but they keep making docs into judges. If anyone s looking for an alternate for next year, keep me in mind.)

The scenario at the 2004 JEMS Games unfolded in three parts. In the first segment, crews had to manage an unresponsive patient with respiratory compromise entrapped within a car following a motor vehicle accident (the Salt Lake City Fire Department contributed several firefighters who gleefully kept bashing at the cars, even when the competitors were nowhere to be seen. Ah, the joys of destruction on the job). The patient s airway was swollen shut, so no ET tube could be passed. A surgical airway was required. Once accomplished, the team went a supine manikin representing the patient, who had now gone into cardiac arrest. Resuscitation continued until either 13 minutes had elapsed or the patient received sodium bicarbonate. The third phase of the problem involved immobilizing and transporting the same patients, CPR in progress, over a set of stairs and risers to the stretcher for transport. My assignment was to act as a floating judge, looking at the overall gestalt of care throughout the process, and insuring that the sequence of events made clinical sense.

I want to mention something about the Aussies' performance. Of all the teams I saw, they did the most incredible job with the victim s family member. All three of the team members spoke to her. They referred to the victim by name and got her involved in helping to care for the patient. The scoring system didn t give any points for style, but if that had become a tiebreaker they would have won hands down. It s the kind of interaction I d want if one of my friends or family members were ill or injured, and it was an absolute model of professional behavior.

Lending the benefit of your expertise

I do need to confess that I actually helped one team to cheat. In this scenario, the person playing the victim s wife was getting out of control, and the paramedic seemed to be at a loss to deal with her. Enter Dr. Bryan Bledsoe, previously serving as Master of Ceremonies, who suddenly claimed to be Geraldo Rivera (a common mistake, to be sure; short, rotund, Caucasian physicians with Texas accents are often confused with New-York born Latino media hounds). Sticking his microphone in the wife s face, he asked her to comment on what was going on. The quick-witted paramedic turned to the wife and, gesturing to Dr. Rivera, said, Keep talking to him. Then, looking at me, he raised a quizzical eyebrow to ask if that was the right thing to do. Starting to laugh, I nodded yes. Couldn t help myself; I d do anything to get that microphone out of my face as well. Success in EMS is often about opportunism.

Finally, I would be remiss if I did not extend a public apology to the lovely, yet unfortunate, Miss Mackenzie, a Laerdal representative from somewhere in Southern California whom I met while wrapping up the evening s games. Mackenzie seemed to have developed the bad luck to have always been in a compromising position with a simulation manikin when someone who could write about it on a Web site was watching. So I happened to stroll by when she was disassembling a full body manikin by removing the crotch plate and unscrewing the bolts holding the legs in place, her hand fully engulfed inside the training aid s intimate regions. And it was me who was nearby when she came walking out of the room holding a dummy s torso in front of her its upper body covered with a T-shirt, its posterior regions open for all to see. I m still waiting for the pictures.

The morning after: Hitting the exhibit hall

Saturday morning found me having breakfast with Gregg Margolis of the National Registry of EMTs, frantically assembling our presentation for later that afternoon (Secret Speaker Tip: I lied just a moment ago when I told you that we write the lecture on the airplane. When there are no handouts or notes, it s because we re writing the talk as we re crossing the street to the conference center). Afterward, it was a trip through the exhibit hall to catch up on the latest in EMS.

I could sit here at the keyboard and write about all the myriad monitors, surplus of supplies and variety of vehicles I viewed as I ventured into the vendor s venue. (Can you English literature majors out there tell that I brought a new translation of Beowulf to read on the plane? I really like alliteration.) That, of course, might be extraordinarily difficult and require an actual thought process. So here s my admittedly unscientific list of the most interesting and unique things I saw:

Trying to get an intraosseous line can be difficult, especially when one has to twist the needle through the bone with the wrist. That s why I ve always been fascinated with devices that make this procedure easier. This year s entry in the How do you ram this thing into a bone? sweepstakes is the EZ-IO device from Vidacare. In essence, this is a cordless drill with an IO needle on the end, not unlike something you d get at Home Depot. It s actually a lot of fun to play with. The folks at the booth were kind enough to let me drill into their plastic bone three or four times. The only problem is that it was hard to tell where I lost resistance and knew the needle had entered the marrow space. This is, I m sure, not the fault of the device, but a function of the fact that I was having a blast with it, having delusions of being Norm Abrams and wondering if I should just take my Black & Decker drill that I use for hanging pictures and transfer it to the first aid kit.

(The idea of trying to detect a loss of resistance does have a special meaning for me. In my last year of medical school, I did a month of neurosurgery. The neurosurgeon at our teaching hospital, an older Filipino physician who had great faith in the ability of a barbiturate coma to fix anything, hadn t quite gotten used to the newfangled electric devices to enter the skull. He still used hand drills to get through the bone. One day, he let me drill the first hole, and as I was happily gnawing away, I asked how far I was supposed to go. He said simply, You ll know. About 10 seconds later, I felt a lurch, and the drill bit sank a good two inches below the skull. He nodded knowingly and said, You through now. Thankfully, the patient had a big subdural hematoma, so all the drill bit hit was blood. Would not have been fun if I had wiped out third grade.)

Lots of EMS services give kids stuffed toys, such as teddy bears, to comfort them during a frightening ride in an ambulance. KidO s has taken this idea and moved one step beyond, creating a truly therapeutic toy. The KidO s bears are molded in bright yellow, green and orange. Made of soft plastic, they have a place in the back to plug in a nebulizer or an oxygen delivery line, and a set of perforations in the front where the mist can emerge as the child holds the toy close to the face. It s a pretty cool idea, although as an adult, I think the bears look more like a squeaky dog toy than a cuddly pet. But I m reminded that when my son was two, he was perfectly happy to share pig ear chewies with the dog. He certainly couldn t tell the difference between a human and a canine treat. Perhaps the KidO s folks have got the right idea after all.

I saw two items that are just truly cool ideas. We all know that pelvic fractures are difficult prehospital injuries. They are incredibly difficult to splint, and unstabilized pelvic fractures may continue to produce severe internal bleeding. About the best we can do is to inflate the top part of a set of MAST pants and that s assuming your agency still carries these on board. The Cybertech T-Pod device is so simple it s brilliant. Essentially, you wrap a piece of Velcro around the victim s hips and then stick on an interlaced set of braces on either end of the binder. You simply pull the braces together, like tightening up the laces on a shoe, and the binder ends come together, stabilizing the fracture. It likely costs quite a bit (no sales folks were at the booth when I stopped by), but it s probably worth it in a severe pelvic crush.

The second really easy, Why didn t I think of that? idea was called the Safe-T-Move Rapid Deployment and Evacuation System. This is basically a little cart into which you slide your backboard and secure it with two tension plates. The beauty of this device is that now the backboard becomes a handcart, allowing you to get patients out of tight spots (like single-wide trailer homes) by securing them to the backboard and bringing them upright to wheel around corners and furniture. It adds stability to the board over that of a manual carry and allows the board to be used to transport equipment or other materials in a more expeditions fashion. Made by Excellence in Care LLC, it s worth a look.

I m not sure if this last thing really counts, but I m going to include it anyway because I think it s fun. Many fire and EMS agencies (including EVAC here in Daytona Beach) use Robotronics animated vehicles in their public safety programs. While the display featured a surprisingly chatty Andy the Ambulance and a very reticent 6' Dalmatian in a fireman suit, it took a glance through the catalog to realize that they were only two members of a family that includes Freddie the Fire Truck, PC the Patrol Car, Pete the Paramedic, Bobby the Boat and Curby the Recycling Robot. I suppose I might be excused for wondering what happens when Freckles the Fire Dog and McGruff the Crime Dog meet Pluggie the Fireplug. If I recall my high school physics lessons about water and electricity, there are probably a lot of short circuits involved. And there s no telling what happens if the guy walking around inside Eddie the Eagle, the gun safety mascot of the National Rifle Association, gets all hot and irritated within the suit. (In an interesting twist of fate, the catalog notes that you have to apply to the NRA to purchase an Eddie the Eagle suit. I think that means that in order to promote gun safety, you have to be approved by an organization that promotes gun ownership. Is it just me, or does this seem backwards?)

While I enjoy looking at products, one of the real highlights of my day involved a St. Bernard (not the St. Bernard of Menthon, the Archdeacon of the Alps who cleared robbers from the mountains and established hospices for travelers, but the four-footed furry kind). Some of you may be aware that the mascot of the Zoll Company is a member of this lifesaving breed. It turns out that the real-life Zoll dog was walking throughout the exhibition. I got to pet this EMS legend, and received a treasured parcel of canine drool in return. It turns out that Zoll was giving away little stuffed St. Bernards wearing red capes, kind of like a patchy Krypto on steroids, as party favors. Mustering some kind of lie about having three children at home, I took three of the dogs. I felt bad about this until I ran into someone toting a cello-wrapped nine-pack of the canines. Who knew dogs came in bulk?

(To demonstrate the fact that I do more than simply wing it in this column although that is most of what I do I d like to reveal the results of my Internet search on St. Bernard. According to catholic-forum.com, there are 10 St. Bernards, three Bernardinos, two Bernadines, a pair of Bernardos and one Bernardina. My favorite is Bernardo de Corleone, who found religion while hiding in a church after killing a man in a duel. He is supposed to have spent the rest of his life in austerity to atone for his sins. Maybe I ve watched way too many movies, but I keep having visions of him getting angry and putting a large mountain dog in somebody s bed.)

With a song in their hearts

Following my lectures that afternoon, I grabbed a bite with my friend Gordy Kokx and his colleagues from Twin Falls, Idaho. I mention this only to note that one of things I failed to investigate during my trip to Idaho last year was the status of fast-food restaurants. We decided to eat at the food court in the Crossroads Center. Of all the ethnic choices for dinner granted, it s industrial-strength ethnic food he chose Chik-Fil-A because he couldn t get it at home.

(Gordy was also kind enough to introduce a new piece of EMS terminology to me. It turns out that some of the women gracing the EMS vendor displays are best referred to as Sim Women, because there is no way nature can make them that beautiful. Except Gordy s wife Kim, of course. Got your back, my friend.)

After a quick change and watching Teen Titans on Cartoon Network (the Mountain Time Zone is a gift for melding television and bar-hopping), it was time to head to Club Vortex for the EMS Karaoke competition. I got there too late to see all the contestants, but a few stay in my mind. Highlights included a guy named Frank who crooned New York, New York after performing a rope trick and someone from Peoria in a doo-rag who tried very hard to sing or shout, or scream, or wail, I m not sure which Jimmy Buffet s Cheeseburger in Paradise. These performances inspired mixed reactions from the judges. Frank s chastisement from them was verbal, including comments like, You put the not in Sinatra, and I haven t heard singing like that since Martha Stewart took the stand. The judges placed external defibrillator pads on another poor performer.

Exploring Utah s hidden treasures

I won t claim to know anything about Utah law, but, for some reason, at 9 p.m. sharp all the alcohol had to come off the dance floor. This prompted a mass exodus of the EMS folks to a bar across the street known as the Port o Call. Of course, this being Utah and all, another twist of the law meant that in order to get into this establishment where alcohol might possibly be served a la carte, I had to become a member of their private club.

(I am not making this up. I quote to you from my receipt, which is headlined Membership Application: I hereby submit the following information to the Board of Directors of Port o Call to evaluate my qualifications to become a member of said club. )

It turns out the membership requirement was a valid ID and $10. So as I watched the gentleman enroll me in his computer, I asked what else I had to do to join the club. Secret handshake? Initiation rite? Perhaps a club motto, or even a special code knock? I was disappointed to find that paying the $10 and showing the ID was all that was required. In retrospect, this was probably a good thing because three hours and several beers later, I surely would have forgotten it all.

Speaking of the laws of Utah, one might surmise that many of them are due to the influence of the Church of Jesus Christ of Latter-Day Saints. I suppose, in some way, that may be true. It s of interest to note, however, that in Salt Lake City non-Mormons are in the majority. The religion s strongholds seem to be in the smaller, less urbanized areas. That may be why at a bookstore downtown, they sell greeting cards that ask, Why do Mormon wives stop at 39 kids? Because 40 is just one too many. And why one can buy a shirt in the Salt Lake Airport promoting Polygamy Porter with the catch phrase, Bring Some Home to the Wives. (Lest you think that Mormons have no sense of humor, let me note that a member of our hospital ED group belongs to the Church, and you simply can t work ED without one.)

In some ways, the influence of the Church is obvious. You can t ignore the Salt Lake Temple or the massive Church Headquarters Building as you look out over the skyline. But the presence of the Church is often much more subtle. For instance, one of the large downtown malls, the ZCMI Center (ZCMI stands for Zion s Mercantile Cooperative Exchange) is closed on Sundays. The other mall (Crossroads Plaza) is open that day. But inside, there s a store that s closed called Dressed in White that you d think would be a bridal shop. Close inspection, though, shows it to be a store where all the clothing is white. It s that way because Mormons need to wear white clothing as they participate in Temple rituals. The presence of the Saints is background noise, but still very real.

For myself, I m OK about the Mormons. I ve always thought you can believe pretty much whatever you wish. As long as it doesn t interfere with either the way I choose to live my life or the rights of others, or is destructive in some way, it s pretty much OK. And as for theology, all belief systems involve some basic level of faith. Jews make a leap of faith to believe in a God; Christians make a second jump to affirm the divinity of Jesus. If the Saints choose to make a third leap in believing that there was another appearance of this same Jesus, so be it.

The Saints are an unfailingly nice people. You could walk up to one and tell them that you are an absolute SOB (and I don t mean shortness of breath ) who has sinned in more ways than God put grains of sand on the beach and that you are fully unrepentant and intend to remain so. They would smile in a knowing way, tell you they really enjoyed your self-deprecating humor and let you go on your way. They don t keep after you the way fundamentalists do, and there s no appearance of judgment or scorn. So it s really hard to not like them. And while I might not agree with some of their beliefs, as they might not agree with a lot of mine, as long as we re all headed the same direction, it s still OK.

(Just so you know I haven t turned into a consistently deep thinker, I ll tell you my best LDS story of all. The last time I was in Salt Lake City, I took a guided tour of Temple Square. As you may know, Mormon youth often leave home for two years on a mission for the faith. For some of them, their mission is to give tours of the Temple complex to visitors. I joined a tour group that was led by one Sister Jackson. Sister Jackson was from Southern California the San Fernando Valley, to be specific. So the tour was an adventure in what can be best described as, if you ll excuse my acknowledged use of the stereotype, blonde theology. As in, This is a statue of Joseph Smith and his brother Hyrum. He was a prophet, which is like a really, really, really holy man who, like, talks to God and stuff. But, like, some people didn t believe him, so they killed him, and that was really, really, really, really bad. Honestly, it was probably as close to converting to any religion as I ve ever been. I went on a second tour just to keep the show going.)

But as much fun as I had at EMS Today, the best single moment of my trip came on the way home. Having been in the Valley of Zion, basking in the palpable spirituality of Temple Square, I boarded the flight home. And at 38,000 feet, somewhere over the mountains, Tom Jones crashed into my brain through a set of $2 headphones. Closer to God than if her were standing on the top of Everest, the deity spoke to me with a Welsh accent. To paraphrase Brigham Young, this was the place.

(Author s note: Thanks to everyone who made my trip a great time I only wish there was space to list everyone by name. And a special thanks to those who helped me frown into my beer late one Saturday evening. Turns out that melancholy is one of my best emotions. It goes well with the tune of Advance, Australia Fair. )


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