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New EMT Skills: In some states, EMT-Bs perform 12-leads & manual defibrillation

Issue 8 and Volume 33.

EMT-Bs in at least three states now perform 12-lead ECGs and transmit the results to hospitals to ensure rapid care for ST-elevation myocardial infarction (STEMI) patients. And EMT-Bs in one„Wisconsin county have recently learned to do manual defibrillation to reduce hands-off time during CPR.

In May,„Ohio gave its EMTs permission to do 12-leads;„North Carolina did the same last year; and EMTs in a few parts of„Wisconsin have been applying 12-leads and transmitting the tracings since 2006. Currently, no state allows EMT-Bs to interpret ECG tracings, but it could be allowed in the future.

˙Some agencies in our very rural areas were EMT-basic [only], so this change was necessary to make sure [every]„EMS agency in the state could have 12-lead capability,Ó says North Carolina EMS Medical Director Greg Mears, MD.

A study involving EMTs with five volunteer fire departments in rural Ross County, Ohio, convinced the state EMS Medical Oversight Committee to change its rules. (Cotton B, Newland RE, Werman HA: ˙Transmission of 12-lead ECG tracings by EMT-basics and EMT-intermediates: A feasibility study.Ó„Prehospital Emergency Care. 12(1):98 [Abstract], 2008.)„

˙When you get out of urban areas, 70% of„EMS is provided by EMT-Bs or -intermediates. Those are the people you really want to do 12-leads because of the long transport times,Ó says Ross County EMS Medical Director Brad Cotton, MD.„

˙In the emergency room, we can hire someone with no medical background and give them two days of training to apply ECGs,Ó says Robert Newland, EMT-P, EMS Liaison for„Adena„Regional„Medical„Center in„Chillicothe,„Ohio, where emergency physicians receive the EMTs_ ECGs and activate the cath lab when appropriate.

EMTs in„Dane County,„Wis., have performed 12-lead ECGs for nearly three years, according to Dane County EMS Medical Director Paul Stiegler, MD.„Dane„County has 21 BLS squads (many of them volunteer) and three ALS squads, only one of which (the Madison Fire Department) provides paramedic 12-lead interpretation.

˙Some services are 15 to 20 miles from a hospital. We were looking at ways to improve door-to-balloon times, and this was logical,Ó Stiegler says. ˙We do know we_re saving 20 to 25 minutes on average in the county.Ó„

The ˙limiting factorÓ is transmission, says Keith Wesley, MD, who was the Wisconsin EMS medical director until recently (and is now the Minnesota EMS medical director). ˙Most programs rely on cell phones, and cellular coverage is extremely spotty in rural areas. [Monitor] manufacturers need to figure out a way to interface with 800-MHz radio systems to transmit the 12-leads.Ó One rural service in„Wisconsin and some squads in„Ross„County solved the problem by buying satellite phones.„

But Cotton says, ˙Sat phones cost about $2,000 a crack with a $50 monthly charge to use the phone.Ó Newland is now trying to raise $300,000 to buy 34 more satellite phones and 13 monitors and upgrade other equipment to outfit 40 EMS squads in„Ross„County and an adjacent county. ˙We_re also trying to get some state and/or federal funding,Ó Cotton says.

Meanwhile, in the past few months,„Dane„County has trainedƒor retrainedƒsome 1,200 EMTs in 23 squads to perform manual defibrillation. ˙We_re now instituting countywide compression-only CPR (or CCR) and, because we don_t want to interrupt chest compressions to use an AED, we_ve trained all basics to recognize V-fib, V-tach and asystole and … shock manually,Ó Stiegler says. ˙The state enabled this many years ago when [it] started defibrillator programs, but then AEDs came along and most EMTs forgot how to do this.Ó„

He notes that the EMTs have made some spectacular saves using CCR, including one patient who was neurologically intact after one hour of chest compressions and 43 minutes of shockable rhythms. ƒMannie Garza

Lifesaving Cell Phones
Cell phones become more versatile every year. Now, besides playing games, taking photos and checking e-mail, you can add software to your cell phone that will store such medical data as your blood type, medications, allergies and implanted device (e.g., pacemaker) information in an Emergency Service Profile (ESP). First responders can access this information from the cell phone_s desktop menu or applications folder where the ESP is identified by a modified Star of Life graphic. MyRapidMD Corp. promises a 24/7 call center will relay the information to medical personnel if the phone is broken or out of power.„

And now, a UC Berkeley team headed by bioengineering professor Boris Rubinsky, PhD, has developed a portable medical ultrasound scanning device that connects to any cell phone that can process multimedia (e.g., video and audio clips). The researchers found the data file for a scan is only 6 KB. The phone transmits raw ultrasound or X-ray scanning data to a central server and sends a picture back to the cell phone.„

According to Rubinsky, this has impressive implications for improving medical care in remote areas far from sophisticated medical equipment. Instead of an entire scanning system, a medical facility would need to possess only the portable scanning device. Rubinsky also sees potential for„EMS use, such as checking trauma patients for internal bleeding.„
ƒAnn-Marie Lindstrom

Who_s Clogging Your EDs?
Multiple factors are causing rapid changes in the demographics of the patients now overfilling„U.S. emergency departments (EDs), resulting in ambulance diversions and long ED turnaround times.

˙The problem of [ED] overcrowding is universal across the„U.S.; it_s happening in urban, suburban areas, and even rural areas,Ó says Linda Lawrence, president of the„American„College of Emergency Physicians (ACEP).„

ED overcrowding is increasingly problematic in growing cities, such as„Tucson, where the recent death of 39-year-old Rob Sweitzer made the news. Sweitzer died in an ED after waiting eight hours to be seen for a severe but likely treatable infection.

When ACEP surveyed 425 New York City ED physicians last year, 69% reported having seen a patient suffer harm because of their inability to be seen in an overcrowded ED, and 28% had seen a patient die as a result.

During a recent House Committee on Oversight and Government Reform hearing on hospital emergency surge capacity for disasters, ACEP members took Bush Administration officials to task for blaming patients for overcrowding.„

Boarding, whereby patients already admitted to the hospital will wait hours in the ED for an available bed, is the predominate cause of routine overcrowding, according to ACEP.

A new study from the Rochester School of Medicine in„New York found long ED boarding times may also actually decrease the likelihood that elderly patients will go straight home from the hospital. (Schneider S, Crane P, Shah M: ˙Prolonged stay in the emergency department is detrimental to older adults.Ó International Conference on Emergency Medicine. Abstract, 2008.) According to this research, the physical and mental stress caused by waiting more than six hours resulted in a fourfold increase in nursing home stays following hospital discharge for geriatric patients.„

Even such vulnerable populations as psychiatric and pediatric patients may wait 24 hours or more for a hospital bed, according to ACEP survey results released in June. Eighty percent of hospitals surveyed either lacked sufficient in-house psychiatric beds or could find no receiving facility with an available bed.

Despite perceptions that uninsured patients cause most ED crowding, a recent study found insured and higher
income patients, as well as people with routine ailments who normally seek care in a doctor_s office, overtook uninsured patients in ED visits between 1996 and 2004. (Weber EJ, Showstack JA, Hunt KA, et al: ˙Are the uninsured responsible for the increase in emergency department visits in the„United States?Ó„Annals of Emergency Medicine. April, 2008 [Epub ahead of print].)

˙The overall rise in emergency department use can probably be attributed to a set of structural problems in the health-care system,Ó reports that study_s lead author Ellen J. Weber, MD, of the„University of„California,„San Francisco. ˙We need to innovate and appropriate solutions to the problem of emergency department crowding, as that hampers access to care for everyone, regardless of income or insurance status.Ó JEMS„„„„„„„„
ƒLauren Coartney

JEMS Awards 2008Ï2009 EMS Research Grant
Since 2005,„JEMS has awarded an annual EMS research grant, in cooperation with the Prehospital Care Research Forum, to encourage„EMS professionals to conduct research in the industry. The 2008Ï2009 grant has been awarded to Christopher Mierek, BS, EMT-P, of the Department of Emergency Medicine,„Upstate„Medical„University,„Syracuse,„N.Y. His proposal, ˙Can Paramedics Make Transport Decisions Based Exclusively on First Impression of Pediatric Patients: The Effect of First Contact,Ó will be endorsed by an award of $2,500 and published in a 2010 issue of„JEMS. To apply for next year_s award, go to„

When Prescription„Drugs Kill
The Florida Medical Examiners Commission reports that prescription drugs killed three times as many people in„Florida in 2007 when compared with deaths caused by all illegal drugs combined. Such strong legal painkillers as Vicodin and OxyContin killed 2,328 Floridians last year; benzodiazepine-based pharmaceuticals (e.g., Valium and Xanax) killed 743; and cocaine, methamphetamines and heroin caused a total of 989 fatalities. According to„The New York Times, ˙The report_s findings track with similar studies by the federal Drug Enforcement Administration, which has found that roughly 7 million people are abusing legal drugs.Ó„

Hot & Cold Conditions Degrade Meds
Eight medications commonly carried in ambulances lose at least 10% of their potency when exposed to extreme temperatures over time. Dustin Gammon, CCEMT-P, of„St. John_s EMS in„Springfield,„Mo., led a study in which researchers in the Department of Chemistry at„Missouri„State„University tested the effect of temperature on 23 prehospital medications. (Gammon DL, Su S, Jordan J, et al: ˙Alteration in prehospital drug concentration after thermal exposure.Ó„American Journal of Emergency Medicine. 26(5):566Ï573, 2008.) The researchers reported in June that extreme heat or cold degraded lidocaine, diltiazem, dopamine, nitroglycerin, ipratropium, succinylcholine, haloperidol and naloxone. Do the ambulances you work in carry refrigerators or coolers? For more information, send an e-mail to„[email protected].

FCC Approves Texts Alerts
The Federal Communications Commission recently adopted a First Report and Order that will enable wireless carriers to broadcast text-based emergency messages to subscribers. The Commercial Mobile Alert System (CMAS) will issue Presidential Alerts regarding national emergencies, Imminent Threat Alerts for emergencies (most likely weather-related) that ˙pose an imminent risk to people_s lives or well-beingÓ and Amber Alerts for missing children. An as-yet-unnamed federal agency will create and transmit the alerts. Wireless carriers that choose to participate in the system will need to comply with the rules included in the order within 10 months after the CMAS agency is announced.

Honesty Is the Best PolicyƒAlways„
When confronted by a federal or state investigator or other law enforcement officials, always tell the truth and never attempt to hide evidence.„

Honesty became the key issue in a recent lawsuit in which an ambulance company was sued by the family of a 3-year-old boy who died after choking on a piece of candy. The family alleged a paramedic negligently inserted an endotracheal tube into the child_s esophagus, but key evidence, including a cardiac monitor strip that was the only irrefutable evidence to show the child_s heart activity at the time of intubation, was ˙missing.Ó The ambulance service agreed to pay $1 million to settle the case after the judge ruled he would tell a jury the defense had ˙spoiledÓ the evidence in bad faith. The ambulance company didn_t want the case in front of a jury when it would appear fishy.

When it comes to litigation or official requests from oversight agencies, it_s imperative to answer questions truthfully and to preserve all evidence. There are serious civil and criminal penalties for lying (committing perjury), and juries don_t look with favor on witnesses or defendants who seem like they_re not telling the full story. Here are some tips for protecting yourself and your service:

  • Document information accurately and objectively on your patient care report (PCR) or other patient-care documents. Stick to the facts: what you can touch, see, hear or be told by the patient and others. Subjective conclusions and opinions have no place in official medical records.
  • Never change a PCR except to add important information you forgot to enter at the time of the incident or to correct specific errors. An amendment or addendum should clearly note the date it was created, who created it and what was added or corrected. Never change documentation to hide or cover up a mistake or potentially wrongful activityƒthat includes attempting to make changes appear they were original entries.„
  • Immediately protect and secure all documents and evidence that might be related to an adverse event.
  • Refrain from destroying documents (except in the normal course of regular document destruction that_s established by company policy and reviewed by legal counsel).
  • Alert management if someone purporting to be an investigator confronts you or you receive an official request to testify or provide documents.
  • Consult an attorney before answering questions or providing documents in response to any request (no matter how official that request might appear).
  • Answer all questions truthfully. Investigators and juries are good at ferreting out dishonesty or inconsistencies in previous testimony.„„„„„„„

The bottom line: Many court cases and investigations go bad not because of the initial conduct that prompted the investigation or court action, but because of attempts to hide the truth or mislead officials. Remember Martha Stewart? She went to jail not because of her stock-trading conduct, which originally prompted the investigation, but because she altered and misrepresented information to investigators after the investigation began. Martha didn_t look good in stripes and neither would you!

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„ for more„EMS law information.