Why Don't We Have That?

Another Perspective

• Bryan E. Bledsoe, DO, FACEP
• Another Perspective
• 2009 May 9

I've been fortunate to be able to travel to various parts of the world and see novel and interesting EMS devices or practices. When I see them, I think many seem like a logical tool or practice for American EMS. So, why don't we have them? Well, I'm not sure – but, for the purpose of discussion, I'll list a few neat things I've seen.

Wireless ECG Electrodes: I first saw wireless prehospital ECG electrodes in Australia and New Zealand. A German ECG manufacturer, Weinmann, has a prehospital ECG monitor/defibrillator that uses Bluetooth technology to transmit the signal from patient ECG electrodes to the monitor. No cables to trip over. No changing of lead wires when the patient is delivered to the hospital. This unit was used in the Australian EMS games in Queensland in 2007. Everything in the United States has Bluetooth technology. Why can't this be added to our 12-lead ECG monitors? 

Hydraulic Stretcher Lifts: Many of the ambulances in the United Kingdom (U.K.) are equipped with a stretcher lift (called a "tail lift" in the U.K.). Once the doors of the ambulance are opened, a hydraulic lift folds down and is located at the same level as the ambulance floor. The stretcher is rolled from the ambulance floor onto the lift and locked. Then, the lift is lowered to ground level, the lock is released, and the stretcher easily rolls off onto the ground. No lifting. No scary moments for the patient. Given the large number of back injuries in EMS, and an increasing trend in patient obesity, the tail lift seems like a no-brainer for EMS. But it's exclusively in Europe. Why aren't these offered on American ambulances?

EMS Barf Bags: An innovative paramedic in Melbourne, Victoria,ttook the circular frame used for embroidery (needlepoint) and painted it orange. The frame, it turns out, is just the right size for a disposable plastic bag. And it's big enough to catch emesis -- even from the most ardent barfer. After the call, the bag is removed from the frame and placed in the biohazard container. I don't know who invented the current kidney-shaped "emesis basin"   --   but they clearly hadn't ever seen somebody who drank a six-pack of malt liquor and ate a large pepperoni pizza throw up in the back of an ambulance. 

Penthrane Inhalers: Australian paramedics often use Penthrane inhalers as an initial pain management tool. The small, disposable inhaler contains a wick where a small amount of the anesthetic agent methoxyflurane is added. The patient breathes the gas mixture and subsequently receives fairly rapid pain relief. Methoxyflurane isn't used anymore in U.S. anesthesia practice (due to hepatic and renal problems at anesthetic doses—not analgesic doses), but is still widely used in Australia and by the Australian Defence forces. This would be a simple, effective, safe and inexpensive tool for American EMS. 

Entonox: Nitrous-oxide is highly effective as a prehospital analgesic agent. In most countries but the U.S., the nitrous oxide (50%) is mixed with oxygen (50%) in a single cylinder. It's fairly inexpensive, safe and easy to use. In the U.S., the Food and Drug Administration (FDA) does not allow pre-mixing of nitrous oxide. Thus, a separate nitrous oxide and oxygen cylinder is required (in addition to a blender to mix the gasses at the 50/50 concentrations). This significantly increases the weight and the cost of the device (and caused it to fall into relative disuse). If Entonox is safe enough to be used in virtually every Commonwealth country, why isn't it safe enough to use here? (After all, we were once a Commonwealth colony.) 

Vacuum Mattresses: When you leave the friendly confines of the U.S., you rarely see a backboard. In all other industrialized countries, EMTs and paramedics don't provide spinal immobilization unless there is a high index of suspicion. When spinal immobilization  is applied, the vacuum mattress is commonly used. The vacuum mattress is highly effective, easy to apply and remove, and actually quite comfortable for the patient (it conforms to their body). Why these aren't used more often in the U.S. is beyond me. They're great, and the paramedics and patients like them. For some reason, we seem determined to subject our patients to an uncomfortable sheet of plywood or plastic.

Proper Medical Helicopters: The Canadians have been operating medical helicopters for almost 30 years. They have never had a fatal crash. In fact, they have had almost no crashes in their history. Why are they successful? First, they fly medium to large helicopters with complete Instrument Flight Rules (IFR) capabilities and full avionics. Most of the medical helicopter operators in Canada use a two-pilot crew configuration with both pilots being IFR rated (much like the U.S. Coast Guard). Also, most Canadian medical helicopters don't make night flights (especially scene flights). Those that do will only respond to designated "heli-stops" where they meet with ground crews (these "heli-stops" are safe areas with pre-mapped GPS approaches). The Canadians have very strict weather minimums and have no qualms about declining a flight that may seem medically inappropriate. Their safety record and years of service speaks for itself.  

Fixed-Wing Air Ambulances: Australia has the landmass of the continental U.S., but has a population similar in number to Texas (about 20 million). The major cities (Brisbane, Sydney, Melbourne, Adelaide and Perth) are clustered on the southern and southeastern seaboard (except Perth, which is on the west coast in Western Australia). Thus, the six states and two territories have a huge geographic area to cover in terms of ambulance need. To deal with this, each state ambulance operates an aviation division. These divisions have both helicopters and fixed-wing aircraft. The helicopters are primarily limited to rescue. The bulk of the work is done by fleets of fixed-wing aircraft (e.g., Beech King Airs) that fly throughout the state, often meeting ground ambulances and picking up multiple patients for transport to higher level hospitals and back to their home communities. The system works very well and is considerably less expensive than the helicopter model used in the States. The fixed-wing aircraft have pressurized cabins, full IFR capabilities, are comfortable and often can fly in weather conditions where a helicopter cannot. And they're considerably less expensive (per hour) to operate compared to helicopters. Plus, they are considerably faster.

These are just a few things to think about. In a few weeks, I'll be off to Busan, South Korea, to speak at an emergency medicine conference. I'm sure I'll come back with some other innovations that we should have in the United States.

• More articles by Dr. Bryan Bledsoe

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• Bryan E. Bledsoe

  Dr. Bledsoe is an emergency physician in Texas. He can be contacted at bbledsoe@me.com. Bledsoe also leads the Street Medicine Society, a group of physicians who got their start as EMS professionals. If you're a physician (MD, DO or equivalent) and have been involved in prehospital care, consider joining the SMS.

  Learn more from Dr. Bryan Bledsoe at the EMS Today Conference & Expo, March 2–6 in Baltimore.