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Military medics train & provide care across the globe

• September 2009 JEMS Vol. 34 No. 9
• 2009 Sept 1

As the U.S. military presence winds down in Iraq and additional forces move into Afghanistan, medics’ roles are undergoing changes many of us back home might not think about. Here’s a glimpse of what our military’s medics are up to.

As the majority of American troops begin leaving Iraq, U.S. Army medics are training Iraqi first responders to better handle emergencies like vehicle accidents—the cause of 80–90% of hospital admissions. During four days of training with two different vehicle scenarios, the Iraqi personnel did well, according to Capt. Pam Foley, civil affairs team leader. 

"The quick responders splinted the fractures and stopped the bleeding before loading them up and moving them inside the treatment facility. Once inside, the doctors performed their specific duties, such as placing airways, chest tubes and some advanced cardiac life support," says Foley on  www.TheRedBulls.org. The plan is for those trained by the Army to train their Iraqi colleagues once a month.

In Afghanistan, Army medics of the 45th Sustainment Brigade (SB) travel with convoys carrying supplies and personnel. Beyond providing immediate medical assistance, the medics teach a 40-hour combat lifesaver course (CLS) to field soldiers. CLS-certified soldiers can extend life expectations of the wounded until medics arrive. The three main areas of instruction are mitigating exsanguination, lung collapse and airway blockage. SB medics also provide CLS and more advanced classes to members of the Afghan army.

No matter how good your training is, moving from a civilian job into a military environment is a dramatic change. Even if you’ve worked in disaster situations with the National Guard or as a reservist, combat conditions present unique challenges that require additional training.

Operation Global Medic is an annual, two-week, medical emergency training exercise hosted by U.S. Army Reserve. This year it was held at Ft. McCoy in Wisconsin, Ft. Gordon in Georgia and Ft. Hunter-Liggett in California. The goal of Global Medic is to prepare reservists for combat conditions, through simulated patient evacuations, mass casualty situations and destruction of the emergency treatment area.

Another valuable benefit of the exercise is that it allows medics from different services to work together. Think of it as mutual aid training. The CBS television affiliate WKBT in La Cross (Wisc.) quotes U.S. Navy Petty Officer Third Class Ryan Fairchild: "It’s just seeing what the different levels of training that the Army has compared to the Navy, and what they can do and what we can do."

For the softer side of military medicine: Beyond the Horizon is a humanitarian program coupled with training exercises, including Medical Readiness Training. Medical personnel get experience in providing care in challenging and sometimes unique environments, while they deliver quality care to people who don’t have access to it. When the Arizona National Guard’s 162nd Fighter Wing spent two weeks in Jamaica, they did simple checkups, diagnosed severe medical conditions, pulled teeth and dispensed eyeglasses. Other units visited Columbia and the Dominican Republic. 

The U.S. military’s goals around the world are growing beyond fighting wars to winning hearts and minds. Military medics are sharing their knowledge and skills to give people all around the world longer, healthier lives.  —Ann-Marie Lindstrom

Odds of Surviving In-Hospital CPR Slim when Over 65
A Medicare study published in the July 2 New England Journal of Medicine shows poor outcomes for in-hospital CPR performed on cardiac-arrest patients older than 65. The research revealed that only about 18% of these patients who received CPR in hospitals around the country from 1992–2005 survived to discharge. William Ehlenbach, MD, of the University of Washington in Seattle, led the team of researchers who analyzed the care of 433,985 Medicare patients for that period.

The study also showed the survival rate has not increased for more than a decade and that blacks had a 23.6% lower survival rate than whites. Of note, black patients (or their families) requested CPR almost twice as often as white patients and fewer black patients had do-not-resuscitate orders. 

Mary Newman, president of the Sudden Cardiac Arrest Foundation ( www.sca-aware.org), says the results are "disappointing." But she added, "In the hospital, you might have patients with co-morbidities." That could explain why in-hospital survival rates are decreasing—96.2% in 1992 and down to 94.8% in 2005—while bystander CPR survival rates are improving. 

Newman would like to see national tracking of sudden cardiac arrest and hospitals’ reporting of survival rates.

Lance Becker, MD, director of the Center for Resuscitation Science at the Hospital of the University of Pennsylvania, has a different interpretation of the study results. He feels hospitals need to do a better job of administering CPR and defibrillation as part of the effort to find better ways to treat cardiac arrest. "It is a system problem, and fixing systems can be challenging," says Becker. 

Becker would like to see improvement in building and coordinating hospital teams to deal with cardiac arrest. "Who’s in charge? Who’s going to rotate in on compressions? We have an enormous opportunity as we realize the importance of minimizing any interruption of CPR, delivering correct ventilation—not too few, not too many—and administering defibrillation at the right time."

He’s also an advocate of CPR-feedback devices that sound an alert when compressions are the wrong rate or depth. Using a feedback device and manikin, Becker found that by the second minute, his compressions were erratic but still "in the zone." Into the third minute, his compressions were inadequate.

The Medicare study raises several issues—racial disparities in survival rates, hospital procedures, better use of new technologies—that call for more investigation. —AML

Is Obesity a Risk Factor for H1N1?
Obesity alone has never been considered a risk factor for seasonal flu. But several H1N1 cases in Michigan are raising questions about obesity’s new role. In the July 10 issue of  Morbidity and Mortality Weekly Report , health officials describe the cases of 10 patients who were very sick; nine were either obese or extremely obese. Two of the three who died had no other known co-morbid conditions.

However, H1N1 experts are interpreting this report with caution. "The numbers here are so small that it is extremely difficult to say whether overweight patients are more likely to become seriously ill from H1N1, whether they are more likely to get infected, or if they are more likely to die when they contract H1N1 infections," says Mike McEvoy, PhD, RN, CCRN, REMT-P, the EMS coordinator for Saratoga County, N.Y. (Watch his webcast at jems.com/webcasts.)  

More cases are needed before any conclusions can be reached, and he noted that an international group of critical care clinicians is compiling 200 case reports of critically ill H1N1 patients for analysis. Their early observations are that the individuals are younger than patients with seasonal influenza, but they are not typically healthy young patients. "The typical critically ill H1N1 patient tends to have other co-morbidities, such as asthma, immune suppression, diabetes and, yes, obesity." 

To McEvoy, the report reminds us that our patients are getting larger. "H1N1 may be yet one more health consequence of the epidemic of obesity in our society," he says.  —Lisa Bell

Names in the News
Alexander G. Garza has been confirmed as Assistant Secretary for Health Affairs and Chief Medical Officer, Department of Homeland Security. Garza specializes in emergency medicine and has had a notable career in both civilian and military roles. He’s currently a staff physician at Washington Hospital Center, a Level I trauma center. He served as associate medical director of emergency medical services for the State of New Mexico and as the director of emergency medical services for the Kansas City Health Department. He has served in the military as a battalion surgeon, as well as a paramedic in Missouri. 

Pro Bono
Avoiding ‘Attitude Creep’
The patient care report (PCR) is the "official record" of the assessment and care provided to the patient—and more. Today’s EMS documentation must pull together the clinical aspects of patient care and the operational and business needs of the agency. The PCR should verify the care and support the medical necessity for an ambulance so that proper reimbursement can be sought and your actions can be justified during a lawsuit or other legal action. 

When reviewing your PCR, outside observers, such as a judge, jury or Medicare reviewer, will often ask: Is it factual and objective? Is it organized and legible? Is it complete and accurate?

Factual:  The PCR should not contain your opinions or beliefs, but should instead be an unbiased description of events and observations. Don’t leave out the bad stuff, but remember that subjective statements have no place in a PCR.

Organized: A good PCR follows a systematic approach with the most critical information "up front." Care should be documented chronologically. Also, if you’re not typing the narratives, you must make sure the PCR is neat and readable. 

Complete: You should never put any false or misleading information on a PCR, and you should always ensure that all relevant sections of the PCR are completed in their entirety. 

One significant problem sometimes seen in documentation is "attitude creep"—letting negative attitudes, emotions and opinions enter the PCR. And worse yet is documentation that shows the field providers were "second guessing" what was wrong with the patient. 

We’ve seen a PCR that had this statement: "The medic feels that the patient’s symptoms are psychosomatic and that his symptoms are not cardiac related, which is why there was no ALS workup performed." But the patient was 70 years old, had a cardiac history, had experienced shortness of breath earlier in the day, and there was no indication that that patient had been hooked to a cardiac monitor! This is dangerous documentation that has no place in professional patient care reporting. And if it’s "negative" in tone, the patient care rendered could be questioned as well. 

The key is to treat every call as if it was your very first. Your honest and unbiased assessment and observations are what our agencies expect and what the patient deserves. Documentation of our patient care is much more than just a "necessary evil" in today’s EMS world—it’s an essential part of being an EMT or paramedic. And the quality of our reports will reflect the quality of our service! 

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
Philips Gets Cooler 
On July 15, Philips Healthcare announced the company’s acquisition of InnerCool Therapies Inc., a pioneer in the field of therapeutic hypothermia. With this acquisition, Philips becomes the only company that offers a comprehensive suite of both surface (external) and endovascular (internal) body temperature management solutions.

New EMS TV Show
A new one-hour medical series called Trauma will premiere Monday, Sept. 28 at 9/8c on NBC. The series, which promises to be like "an adrenaline shot to the heart," focuses on the encounters of EMS professionals based out of the fictional San Francisco City Hospital. Medtec Ambulance Corp. is providing vehicles to the series. Watch clips at www.nbc.com/trauma,  

Now Available:Education Standards Gap-Analysis Template
Developed to support national implementation of the EMS Education Agenda for the Future, the 2009 National EMS Education Standards Gap Analysis Template describes key transition elements and provides greater understanding about the differences between the National Standard Curricula and the recently published EMS Education Standards. Find it at www.nasemso.org/EMSEducationImplementationPlanning/Toolkit.asp

"FIRESTORM" documentary about LA Fire Department at lafd.blogspot.com/2009/06/who-will-rescue-rescuers.html  

New skills training company Critical Information Network (CiNet) debuts:  www.criticalinfonet.com

Video and free CE on early detection of brain aneurysms at www.bafound.org

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