Administration and Leadership, Columns, Training

Not All Forms of Patient Care Can Be Taught in the EMS Curriculum

Issue 9 and Volume 40.

I’ve been working in my garage to develop an EMS time machine, a Star Trek-type apparatus that an EMT or paramedic can sit in and be shot back to the time of their birth and early childhood, or, with the turn of a dial, sent to age ranges 1–17, 18–30, 60–80 and 81–98. It will allow EMS personnel to see and feel things most have to wait 30 years to experience. My Advanced Simulation Sensory Modulator and Normal-Condition (ASSMAN) machine and its multiple sensors will do it all.

In the “low” setting (age 1–17), the rider will experience what it feels like to be a meconium aspirate at birth; have a high fever and convulsions that can’t be stopped at 3 months; have croup at 9 months; and experience a series of concussions while playing sports in high school. It will involve them in a virtual car crash resulting in a dissociative injury where their vertebrae are separated. They’ll learn what can happen when a C-collar is put on inappropriately by an EMS crew, excessively stretching their vulnerable spinal cord and causing their condition to deteriorate to cardiac arrest.1

When set on the “middle 1” setting (age 18–30), sensors, electrodes and pain generators attached to their body will make them feel the pain that results from a fracture/dislocation of their knee. They’ll then experience what it’s like to have an EMS crew not properly splint their injury and allow bone grating, muscle damage, and tears to ligaments, tendons and blood vessels. In addition, they won’t be properly medicated for their pain, and the machine’s low-energy shocks will remind them of that.

Their inappropriate fracture/dislocation management will also result in their peroneal nerve being stretched or torn, and they’ll feel what it’s like to suffer foot drop—a condition that will leave them with a permanent highstep walk.2

EMS time machine riders will also be sent to a remote battlefield of Afghanistan where an improvised explosive device will blow off two of their extremities and subject them to a traumatic brain injury (TBI) that exposes them to recurrent seizures at the age of 22.

With the click of a switch, I’ll then transport them back to the U.S. and, 12 months later, they’ll suffer seizures while at a bar and have responders, unaware they’re an injured veteran, treat them in a disrespectful manner, referring to them as a brain-damaged system abuser.

There isn’t enough time for instructors to interject important concepts or care not emphasized in the ‘formal’ curriculum.

With the flip of another switch, the person will be transformed from patient to provider and, having failed to recognize or correctly approach this post-traumatic/TBI patient, be shot in the chest and upper thigh by the disoriented and overstressed patient with a gun in his pocket that wasn’t detected by the provider because he failed to perform a complete secondary assessment and discover it.

The provider will then experience what it’s like to rapidly deteriorate and die from exsanguination when the arriving BLS crew isn’t allowed to pack the chest wound with gauze or wound clot dressings and doesn’t carry tourniquets to stop extremity bleeding.

On the “middle 2” setting (age 31–60), they’ll virtually relive traumatic calls involving children, suicide attempts, clinical depression and the loss of loved ones, the breakup of a marriage or relationships, and feel what it’s like to have to go to work and manage similar calls while suffering from post-traumatic stress and sleep deprivation. They’ll also be overcome by toxic fumes when they open a car door at the scene of a chemically assisted suicide.

On the “high 1” setting (age 60–80), a weight accelerator will fill a water suit, increase their weight by 150 pounds and force them to experience what it feels like to walk up three flights of stairs in a hot apartment building that lacks elevators and air conditioning.

They’ll suffer from pressure sores and skin tears from their morbid obesity and develop chronic asthma and diabetes that further complicates their lives and physical condition. They’ll feel what it’s like to have sleep apnea, forced to sleep on their back with their head high on two pillows and use a continuous positive airway pressure (CPAP) unit. They’ll then experience severe respiratory distress when transported flat by an EMS crew or handcuffed on their chest and stomach by police officers uneducated about positional asphyxia.

On the “high 2” setting (age 81–98), they’ll experience what it’s like to have dementia, vision loss, chronic arthritis and constant back pain. Sensors will then deliver electrical stimulus to their torso to let them feel the constant, excruciating pain caused by shingles.

There will be no bell alarms or LEDs that light up. The person in the virtual time machine will go into respiratory and cardiac arrest if (or when) care isn’t promptly or properly administered.

People who know me well realize this project isn’t true because there isn’t enough room in my garage to even walk, let alone build my dream device. But, with today’s technology and the marriage of existing civilian and military simulators, computer applications and 3D headsets and sensor/Taser capabilities, it will be possible to approach this level of education soon.

Why We Need to Go to this Next Level

Education and experience are two of the most important cornerstones of EMS. When I lecture, I’m keenly aware I’m responsible for making sure the learners understand conditions and issues, and the correct (and incorrect) ways to approach or treat each one.

As is usually the case in EMS, instructors are seasoned, experienced providers who have a depth of experience in the field. However, there are several built-in limitations to what they’re allowed to, or able to, teach.

First, in EMT and paramedic education, a specific, standardized curriculum and recognized EMS textbooks must be used, and instructors aren’t allowed much leeway to stray from the formal curriculum.

Second, there isn’t enough time for instructors to interject important concepts or care not emphasized in the “formal” curriculum.

And third, although experienced, many instructors haven’t personally or physically experienced many of the maladies and injuries their students will be faced with in the field.

Although the curriculums attempt to give learners a well-rounded education on the illnesses and injuries they’ll most often be confronted with, there are a whole host of other problems and conditions they’ll be faced with that, while not all critical or life threatening, they should be prepared to manage, not just for the patient’s sake but for their own sake. These include EMS responses to domestic violence calls and other situations where patients, often overdosed, intoxicated, emotionally distraught or suicidal, will seek to harm the responding providers.

Conditions outside the norm for pediatrics, geriatrics and bariatrics must be presented to EMS and we need to include those that are emphasized in nursing and physician curriculums in EMS curriculums.

What follows are just a few of the situations and conditions that can’t be found in today’s EMS textbooks that need to be addressed. Hopefully educators, authors and manufacturers will begin to develop new technology, continuing education modules and methods to enable us to teach these important issues and conditions to EMTs and paramedics.

Ventilator-Associated Pneumonia

Training programs teach paramedics how to intubate and EMTs how to assist in intubation by retrieving tubes from kits and “preparing” them for insertion, but they rarely discuss the need to maintain tube sterility and avoid contamination before the tube is introduced into the patient’s trachea.

Ventilator-associated pneumonia (VAP) is pneumonia that frequently occurs after patients have been intubated and received mechanical ventilation. The problem is exacerbated when they arrive at the hospital, end up in the ICU on a mechanical ventilator and develop pneumonia—the second most common nosocomial infection in critically ill patients, affecting 27% of these patients.3

Eighty-six percent of VAP occurrences are associated with mechanical ventilation. Between 250,000 and 300,000 cases per year occur in the U.S. alone, which is an incidence rate of 5–10 cases per 1,000 hospital admissions. And the mortality attributable to VAP has been reported as high as 50%.3

Beyond mortality, the economics of VAP include increased ICU lengths of stays (from four to 13 days). Incremental costs associated with VAP have been estimated between $5,000 and $20,000 per diagnosis.3

So, if a tube is handled by bare hands, is placed on the street, a towel or the patient’s chest; if the patient’s airway isn’t properly suctioned; or if a dirty stylette is placed into the endotracheal tube before it’s placed in the patient’s trachea, bacteria will be introduced into the patient’s trachea and the patient will be at risk of death not only from their critical illness but also from secondary processes such as nosocomial infection.3

In one system, it was determined that 50% of congestive heart failure (CHF) patients intubated in the field ended up with VAP, with the potential for 50% of those patients dying in the hospital. The problem was significantly reduced when that system educated its crews about VAP and moved to use of CPAP over early intubation of CHF patients.4

Peroneal Nerve Injury

Look up peroneal nerve injury in an EMS textbook. You won’t be able to find it. Yet, we handle (or mishandle) bad fractures every day and have the potential to cause peroneal nerve injury because we’re not educated about it.

The common peroneal nerves provide sensation to the anterior and lateral parts of the legs and top of the feet. They innervate muscles in the legs, which lift the ankle and toes upward (dorsi flexion).2,5

A peroneal nerve injury (also called “foot drop,” “drop foot” or “high-step walk”) is a peripheral nerve injury that affects a patient’s ability to lift their foot at the ankle. It can be caused by an injury to the spinal cord, injuries to the knee, or joint dislocation or fracture, and can be a symptom of a more serious injury such as a nerve compression or herniated disc.5

But, EMS crews can unknowingly cause peroneal nerve injury and permanent foot drop by not properly splinting a patient and allowing the peroneal nerve to stretch or tear.

Conclusion

Providers have to learn a lot of things that aren’t on the standard EMS “script” because there’s only so much time in classes to teach the basics.

We need forward-thinking approaches and technology to teach new and existing providers conditions and situations they can’t get in the standard classroom or have to wait until the 11th hour of their EMS career to experience.

Work with your providers and co-workers to develop your own list of topics that need to be addressed and develop continuing education programs, simulations and fact sheets that pass along this valuable information.

JEMS is committed to continually addressing these important areas that can make a difference and save your life and the lives of your patients.

REFERENCES

1. Persse D, Ben-Galim P, Hipp J. (2010.) C-collar or de-collar: Are cervical devices harmful?Gathering of Eagles. Retrieved Aug. 4, 2015, fromwww.gatheringofeagles.us/2010/Presentations/Persse%20C-Collars2.pdf.

2. Heightman AJ. Articulating knee injuries: Placing proper emphasis on the recognition & stabilization of severely dislocated knees. JEMS. 2004;29(7):46–55.

3. Centers for Disease Control and Prevention. (May 17, 2012.) Ventilator-associated pneumonia (VAP). Retrieved Aug. 4, 2015, from www.cdc.gov/HAI/vap/vap.html.

4. Hewett M, Persse D. CPAP partnership that makes sense: Hospital & EMS systems form a unique agreement. JEMS. 2007;32(10):S20–S21.

5. Johns Hopkins Medicine. (n.d.) Peroneal nerve injury (foot drop). Retrieved Aug. 4, 2015, fromwww.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve_surgery/conditions/foot_drop_injury.html.

 

Administration and Leadership, Columns, Training

Not All Forms of Patient Care Can Be Taught in the EMS Curriculum

Issue 9 and Volume 40.

I’ve been working in my garage to develop an EMS time machine, a Star Trek-type apparatus that an EMT or paramedic can sit in and be shot back to the time of their birth and early childhood, or, with the turn of a dial, sent to age ranges 1–17, 18–30, 60–80 and 81–98. It will allow EMS personnel to see and feel things most have to wait 30 years to experience. My Advanced Simulation Sensory Modulator and Normal-Condition (ASSMAN) machine and its multiple sensors will do it all.

In the “low” setting (age 1–17), the rider will experience what it feels like to be a meconium aspirate at birth; have a high fever and convulsions that can’t be stopped at 3 months; have croup at 9 months; and experience a series of concussions while playing sports in high school. It will involve them in a virtual car crash resulting in a dissociative injury where their vertebrae are separated. They’ll learn what can happen when a C-collar is put on inappropriately by an EMS crew, excessively stretching their vulnerable spinal cord and causing their condition to deteriorate to cardiac arrest.1

When set on the “middle 1” setting (age 18–30), sensors, electrodes and pain generators attached to their body will make them feel the pain that results from a fracture/dislocation of their knee. They’ll then experience what it’s like to have an EMS crew not properly splint their injury and allow bone grating, muscle damage, and tears to ligaments, tendons and blood vessels. In addition, they won’t be properly medicated for their pain, and the machine’s low-energy shocks will remind them of that.

Their inappropriate fracture/dislocation management will also result in their peroneal nerve being stretched or torn, and they’ll feel what it’s like to suffer foot drop—a condition that will leave them with a permanent highstep walk.2

EMS time machine riders will also be sent to a remote battlefield of Afghanistan where an improvised explosive device will blow off two of their extremities and subject them to a traumatic brain injury (TBI) that exposes them to recurrent seizures at the age of 22.

With the click of a switch, I’ll then transport them back to the U.S. and, 12 months later, they’ll suffer seizures while at a bar and have responders, unaware they’re an injured veteran, treat them in a disrespectful manner, referring to them as a brain-damaged system abuser.

There isn’t enough time for instructors to interject important concepts or care not emphasized in the ‘formal’ curriculum.

With the flip of another switch, the person will be transformed from patient to provider and, having failed to recognize or correctly approach this post-traumatic/TBI patient, be shot in the chest and upper thigh by the disoriented and overstressed patient with a gun in his pocket that wasn’t detected by the provider because he failed to perform a complete secondary assessment and discover it.

The provider will then experience what it’s like to rapidly deteriorate and die from exsanguination when the arriving BLS crew isn’t allowed to pack the chest wound with gauze or wound clot dressings and doesn’t carry tourniquets to stop extremity bleeding.

On the “middle 2” setting (age 31–60), they’ll virtually relive traumatic calls involving children, suicide attempts, clinical depression and the loss of loved ones, the breakup of a marriage or relationships, and feel what it’s like to have to go to work and manage similar calls while suffering from post-traumatic stress and sleep deprivation. They’ll also be overcome by toxic fumes when they open a car door at the scene of a chemically assisted suicide.

On the “high 1” setting (age 60–80), a weight accelerator will fill a water suit, increase their weight by 150 pounds and force them to experience what it feels like to walk up three flights of stairs in a hot apartment building that lacks elevators and air conditioning.

They’ll suffer from pressure sores and skin tears from their morbid obesity and develop chronic asthma and diabetes that further complicates their lives and physical condition. They’ll feel what it’s like to have sleep apnea, forced to sleep on their back with their head high on two pillows and use a continuous positive airway pressure (CPAP) unit. They’ll then experience severe respiratory distress when transported flat by an EMS crew or handcuffed on their chest and stomach by police officers uneducated about positional asphyxia.

On the “high 2” setting (age 81–98), they’ll experience what it’s like to have dementia, vision loss, chronic arthritis and constant back pain. Sensors will then deliver electrical stimulus to their torso to let them feel the constant, excruciating pain caused by shingles.

There will be no bell alarms or LEDs that light up. The person in the virtual time machine will go into respiratory and cardiac arrest if (or when) care isn’t promptly or properly administered.

People who know me well realize this project isn’t true because there isn’t enough room in my garage to even walk, let alone build my dream device. But, with today’s technology and the marriage of existing civilian and military simulators, computer applications and 3D headsets and sensor/Taser capabilities, it will be possible to approach this level of education soon.

Why We Need to Go to this Next Level

Education and experience are two of the most important cornerstones of EMS. When I lecture, I’m keenly aware I’m responsible for making sure the learners understand conditions and issues, and the correct (and incorrect) ways to approach or treat each one.

As is usually the case in EMS, instructors are seasoned, experienced providers who have a depth of experience in the field. However, there are several built-in limitations to what they’re allowed to, or able to, teach.

First, in EMT and paramedic education, a specific, standardized curriculum and recognized EMS textbooks must be used, and instructors aren’t allowed much leeway to stray from the formal curriculum.

Second, there isn’t enough time for instructors to interject important concepts or care not emphasized in the “formal” curriculum.

And third, although experienced, many instructors haven’t personally or physically experienced many of the maladies and injuries their students will be faced with in the field.

Although the curriculums attempt to give learners a well-rounded education on the illnesses and injuries they’ll most often be confronted with, there are a whole host of other problems and conditions they’ll be faced with that, while not all critical or life threatening, they should be prepared to manage, not just for the patient’s sake but for their own sake. These include EMS responses to domestic violence calls and other situations where patients, often overdosed, intoxicated, emotionally distraught or suicidal, will seek to harm the responding providers.

Conditions outside the norm for pediatrics, geriatrics and bariatrics must be presented to EMS and we need to include those that are emphasized in nursing and physician curriculums in EMS curriculums.

What follows are just a few of the situations and conditions that can’t be found in today’s EMS textbooks that need to be addressed. Hopefully educators, authors and manufacturers will begin to develop new technology, continuing education modules and methods to enable us to teach these important issues and conditions to EMTs and paramedics.

Ventilator-Associated Pneumonia

Training programs teach paramedics how to intubate and EMTs how to assist in intubation by retrieving tubes from kits and “preparing” them for insertion, but they rarely discuss the need to maintain tube sterility and avoid contamination before the tube is introduced into the patient’s trachea.

Ventilator-associated pneumonia (VAP) is pneumonia that frequently occurs after patients have been intubated and received mechanical ventilation. The problem is exacerbated when they arrive at the hospital, end up in the ICU on a mechanical ventilator and develop pneumonia—the second most common nosocomial infection in critically ill patients, affecting 27% of these patients.3

Eighty-six percent of VAP occurrences are associated with mechanical ventilation. Between 250,000 and 300,000 cases per year occur in the U.S. alone, which is an incidence rate of 5–10 cases per 1,000 hospital admissions. And the mortality attributable to VAP has been reported as high as 50%.3

Beyond mortality, the economics of VAP include increased ICU lengths of stays (from four to 13 days). Incremental costs associated with VAP have been estimated between $5,000 and $20,000 per diagnosis.3

So, if a tube is handled by bare hands, is placed on the street, a towel or the patient’s chest; if the patient’s airway isn’t properly suctioned; or if a dirty stylette is placed into the endotracheal tube before it’s placed in the patient’s trachea, bacteria will be introduced into the patient’s trachea and the patient will be at risk of death not only from their critical illness but also from secondary processes such as nosocomial infection.3

In one system, it was determined that 50% of congestive heart failure (CHF) patients intubated in the field ended up with VAP, with the potential for 50% of those patients dying in the hospital. The problem was significantly reduced when that system educated its crews about VAP and moved to use of CPAP over early intubation of CHF patients.4

Peroneal Nerve Injury

Look up peroneal nerve injury in an EMS textbook. You won’t be able to find it. Yet, we handle (or mishandle) bad fractures every day and have the potential to cause peroneal nerve injury because we’re not educated about it.

The common peroneal nerves provide sensation to the anterior and lateral parts of the legs and top of the feet. They innervate muscles in the legs, which lift the ankle and toes upward (dorsi flexion).2,5

A peroneal nerve injury (also called “foot drop,” “drop foot” or “high-step walk”) is a peripheral nerve injury that affects a patient’s ability to lift their foot at the ankle. It can be caused by an injury to the spinal cord, injuries to the knee, or joint dislocation or fracture, and can be a symptom of a more serious injury such as a nerve compression or herniated disc.5

But, EMS crews can unknowingly cause peroneal nerve injury and permanent foot drop by not properly splinting a patient and allowing the peroneal nerve to stretch or tear.

Conclusion

Providers have to learn a lot of things that aren’t on the standard EMS “script” because there’s only so much time in classes to teach the basics.

We need forward-thinking approaches and technology to teach new and existing providers conditions and situations they can’t get in the standard classroom or have to wait until the 11th hour of their EMS career to experience.

Work with your providers and co-workers to develop your own list of topics that need to be addressed and develop continuing education programs, simulations and fact sheets that pass along this valuable information.

JEMS is committed to continually addressing these important areas that can make a difference and save your life and the lives of your patients.

REFERENCES

1. Persse D, Ben-Galim P, Hipp J. (2010.) C-collar or de-collar: Are cervical devices harmful?Gathering of Eagles. Retrieved Aug. 4, 2015, fromwww.gatheringofeagles.us/2010/Presentations/Persse%20C-Collars2.pdf.

2. Heightman AJ. Articulating knee injuries: Placing proper emphasis on the recognition & stabilization of severely dislocated knees. JEMS. 2004;29(7):46–55.

3. Centers for Disease Control and Prevention. (May 17, 2012.) Ventilator-associated pneumonia (VAP). Retrieved Aug. 4, 2015, from www.cdc.gov/HAI/vap/vap.html.

4. Hewett M, Persse D. CPAP partnership that makes sense: Hospital & EMS systems form a unique agreement. JEMS. 2007;32(10):S20–S21.

5. Johns Hopkins Medicine. (n.d.) Peroneal nerve injury (foot drop). Retrieved Aug. 4, 2015, fromwww.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve_surgery/conditions/foot_drop_injury.html.