Stop the Bleed

The world has changed drastically in the last 30 some years. Even our language has evolved. No longer do we use terms like; pay phones, rotary dials, transistor radios, beepers, cassette recorders. We also, no longer use that technology. We are now somewhere between self-driving cars and booking tickets to Mars.
Healthcare has also changed with the times, and some diseases once in circulation have been eradicated. Unfortunately though, new strains of 'not so good stuff' have come into the present.

EMS is trying its best to keep up. One of the things we have to look forward to is a discussion on whether or not to train EMT's in scenes of ASHE (active shooter/hostile event). If you are interested in this topic, EMSWORLD magazine (March 2017 / Vol. 46, NO. 3) has excellent articles on the subject. One is a roundtable discussion with 4 top experts and I strongly encourage you to find the publication and read the article.

One of the first questions they ask of these experts is whether or not EMS should be more proactive in assisting casualties in mass shootings? Some of the experts in this article say scene safety might be an illusion. The questions they bring up must cause us to think. No one can truly say that a scene is absolutely safe until you are far from it, in the safety of your ambulance, driving away. They will not be asking EMT's to go into the line of fire but all of them agree that the emergency system needs a solution.

Another question brought up in this article is weather it is feasible to expect the police to help with the medical stabilization of patients. E. Reed Smith, MD states, " the law enforcement officer who is no longer stopping the killing can very quickly switch over to stopping the dying." He goes on to say that the scope of practice for the police would be very much the same as a current lay-person's knowledge: bleeding control, tourniquet use, compression only CPR, public-access defibrillation, and maintaining body temperature.

What I found enlightening is that some of these experts are advocating for hemorrhage control kits to be displayed right beside AED's in public places. In fact there is a program out there called Stop the Bleed. The goal of the Stop the Bleed program is to make training in bleeding control as common as CPR training and Combat Application Tourniquets (C-A-T's) publicly available, with enough pressure bandages to treat 8 patients, mounted alongside your public-access AED. The article states, "The recommendation to train citizens and all first responders to stop bleeding came out of the Hartford Consensus." "This committee was formed in direct response to the 2012 mass shooting at Sandy Hook Elementary School in Newtown, CT, which left 20 children and 6 staff members dead."

Ed Racht, MD, sums it up and says that an important part of the strategy of responding to ASHE's is preparing law enforcement and other responders for aggressive hemorrhage control. "If law enforcement-which has the training and expertise to go deeper into the uncontrolled hot zone –can rapidly identify and control significant bleeding and bring patients to safety, they can have a significant impact on patient outcome and loss of life." The question is, will they want to?

A similar thing took place when many fire departments strongly encouraged the fire fighters to become CFR's (Certified First Responders), which is the level below EMT. A very large amount of fire fighters I have come across clearly stated to me that all they wanted to do was fight fires. Maybe this narrow tunnel thinking needs to change to a much broader vison and training in the present world of violence and terrorism. www.dhs.gov/stopthebleed

PTSD in EMS

One of the most important considerations in EMS today should be the mental health of our first responders and care providers. With traumatic situations at an all-time high, EMS providers, along with all uniformed first responders, are seeing an increase in horrific situations. The end result of these visual images, in addition to the pain and suffering of fellow human beings becomes the perfect recipe for PTSD.

The most significant contributor to PTSD is not only what you see and hear but also denial of the impact of these memories that become imprinted in our brains. Our EMT Courses teaches us the importance of CISM (Critical Incident Stress Management) but is it really out there and readily available? And if it is, what about the social stigma related to our "strong & brave" going for mental help?

"We suffer what I call cultural brainwashing," says Jeff Dill, a captain at the Palatine Rural Fire Protection District in Illinois. "Once we put this uniform on, we're expected to act a certain way: Be strong. Don't show weakness. Don't be the weak link of the company – we can handle problems on our own.....We forget we're human beings first....

Preventing burnout in the EMS System can also help with keeping PTSD at bay.

One study found that the top causes of emergency services burnout are:

  • Abuse of the 9-1-1 system

  • Extensive time shift length

  • Extended length of service

  • High call volume

  • Sleep deprivation

  • Lack of administrative support

If you find that you are experiencing any of the signs & symptoms below:

  • Flashbacks

  • Nightmares

  • Hopelessness

  • Loss of interest in normal activities

  • Loss of interest in normal activities

  • Irritability and anger

  • Insomnia

  • Difficulty concentrating

  • Difficulty making decisions

  • Overuse of alcohol

  • Misuse of drugs

It might be time to take action. The newest weapon in the fight against PTSD is called First Response Resiliency Curriculum Training. Take some time and do a little research. It just might be time to invest in YOU. Find a program near you that offers CISM or First Response Resiliency Training. One of the best methods of releasing the trauma of PTSD is being able to talk to people who also work in the same field and have similar experiences. You are worth it!

Delayed EMS Responses – Causes and Solutions

Will you survive a life threatening medical emergency in the US?
Depends on where you live.
Collapse in Seattle from cardiac arrest – you're guaranteed defibrillation within minutes. Collapse in Washington? Call a cab.
In the fifty largest US cities, about 9,000 people collapse from cardiac arrest caused by a short circuit in the heart. This is a very treatable issue – all it needs is a shock from an AED machine. Yet only about 10% are saved.
Something is clearly wrong. True; in a large percentage of EMS calls, a longer response time will not cause harm to the patient. But what about all the other times, when every second counts?

Let's take a deeper look at the problem.

1) Insufficient Ambulances

Before we get into all the complicated issues, let's get down to the most obvious problem – lack of ambulance units. As populations in different areas grow and change, the need for ambulances changes as well – but EMS systems are not evolving enough.
Recently, Mayor Martin J. Walsh of Boston announced that Boston Emergency Medical Service had begun training a new class that would increase their EMS count by 24 employees.
It's time for other cities and towns to follow their lead and ramp up the number of ambulances.

2) Dispatch Errors

Last year, two young siblings, Ayina and Jai'Launi Tinglin, were killed in a Far Rockaway fire. EMS did not reach the scene until 20 minutes after the call was received.
The cause? Personnel errors preceding the dispatch.

Why the errors? Not enough training, says Jack Tanski, a telecommunicator for the Colony Police Department in Latham, NY, and a former paramedic.

Much more funds and effort needs to be invested in training and overseeing EMD. At the moment, in many agencies the management uses the communications center as a "dumping ground" for women who are on maternity leave or employees on light duty.

The outcome?
A dispatch center full of improperly trained employees who don't even want to be there. Like every other part of the EMS system, EMD needs a clear protocol and oversight. "EMD is like the kid in the family who gets the hand-me-downs," said Jeff Clawson, MD, owner of Medical Priority Consultants, Inc., in Salt Lake City, UT, "EMS buys all the fire engines, helicopters and equipment, but balks at buying a protocol that may cost $300-about the same as a battery for a defibrillator and half as much as the chair a dispatcher traditionally sits in."
In addition, personality needs to be assessed when hiring dispatchers. A good dispatcher must have good interpersonal skills and a calm, reassuring manner.

3) Lack of Teamwork Between the EMS System and the Fire Department

The fact is that firefighters today are more likely to respond to medical emergency calls than to actual fires. Yet the culture doesn't yet reflect that. Firefighters went into their careers expecting to fight fires, and not to plug in AEDs – so it is unsurprising that it is often difficult for them to respond properly.
In one city, firefighters median response time to a dumpster fire – which requires donning protective boots, pants, coats and breathing apparatus – was faster than their response to a cardiac arrest call. And this is understandable. Medical treatment was not what they signed up for. It is not what they were trained for.
In addition, infighting and turf wars between fire departments and ambulance services cause deadly delays.
Maybe it is time for firefighter recruiting and training to be changed to reflect the new reality. Let's develop a new culture of partnership between EMS and fire departments.

4) Inability to Find Location of Emergency

Paper maps are basically extinct, right?
Wrong.
Many city's ambulances have high priced GPS systems – but their paramedics still use time consumer paper maps. Why?
Because those GPS systems are only there to let the dispatchers keep track of the ambulances, not to provide direction to the drivers. Although this does cut 30-plus seconds off response time, there's no reason the EMS responders themselves shouldn't have GPS to help them navigate the streets.
The FDNY says that it isn't so necessary since most EMTs work in the same areas each day. But even in an area that's basically familiar, a GPS can go a long way in helping to locate a specific address and the best route to get there.

5) Calls Coming During a Shift Change

From his apartment window, Jonathan Agronsky saw Julia Rusinek on the ground. He rushed to the firehouse less than a block from where she fell – the firefighters there said a fire engine from another station farther away was on the way. Why couldn't they come? Their ambulance crew was going off duty.
Last December, a paramedic was dispatched to a report of a cardiac arrest at 6:01 – but his shift had ended at 6. What did he do? He drove back to his firehouse to go off duty, and firefighters performed CPR on the victim for 25 minutes until the new paramedic crew drove to the scene.
It is not certain if such scenarios take place often, but it is definitely an issue that should be address, perhaps by offering a significant financial incentive for post-shift calls.

EMTs continue to be devoted to their jobs and saving lives. Putting some of the above changes into practice can go a long way towards increasing efficiency and making things easier for EMTs everywhere.

Responding to Violent Protests

Especially after the protests following the recent election of Donald Trump, you may be getting a feeling that you're reliving the days of the 1960's Civil Rights Movement. Many of these protests have unfortunately turned into full-scale violent riots – including pepper spraying, effigy burning and window smashing.

Unfortunately, EMS responders have been the targets of bricks, bottles and even Molotov cocktails when responding to such situations. In light of this, it's a good time for EMTs to brush up on how to best respond to emergencies at the site of a violent protest, especially in places like New York, where protests are a frequent occurrence.

Anticipating the Violence

The first step to proper response is always preparation – and part of that is recognizing when events are likely to turn violent. Some of the most common are:

  • Peaceful demonstrations

  • Planned political conventions (interrupted by activists)

  • Racially charged events (i.e. police shooting of a minority)

  • College campus sporting events

Advance Preparation

Though management planning is not an EMT requirement, you can approach the management at your agency before such events and double check to make sure they're prepared with:

  • Extra staffing and equipment

  • Method of communication with other agencies that would be involved

In many cases, your agency may create task forces to ensure proper coordination and safety for everyone involved.

EMT Personal Preparation

What you can do on your own is prepare yourself, your ambulance and your equipment for the special circumstances.

  • Make sure you have a helmet and a clearly marked EMS jacket at all times

  • Remove any axes, hooks or poles that are accessible to outsiders

  • Remove scissors or sharp instruments from your pockets and equipment bags

  • Place duct tape on the windows of your vehicle in an "X" shape

  • Expect to see many patients with abrasions, sprains, lacerations, tear gas exposures and breathing difficulties. Prepare your equipment appropriately.

Responding

Once the violence has begun and calls start coming in, never respond before making sure you'll be safe.

  • Make sure your dispatcher has confirmed with police that the area is secure.

  • Once on the scene, seek out a law enforcement individual to confirm that you are in a safe zone.

  • Do not enter the scene if there are no law enforcement agencies around

  • Feel free to request police assistance if worried that a patient will turn violent

  • Be prepared to abandon the scene at the first sign of danger

  • Move in and out quickly – only basic patient assessment. More thorough assessments will have to wait until you and the patient are both secure.

No matter how passionate you are about saving lives, never forget to put your own safety first. It's not worth risking your life to treat someone's broken leg or burn.

Election 2016: What EMTs Want to Know

Every group looks to the presidential candidate that will address the issues they care about most. But what about EMTs? What candidate would be best for us? With Election Day almost here, it is interesting to ponder what each of the candidates would do about several hot issues currently affecting EMTs. Yes, health care is often discussed by both candidates, but it is usually just a general back and forth about the state of Obamacare. But though the average voter may not know much about these more specific topics that concern EMTs, they are affecting hundreds of thousands of people every day and deserve to be addressed.

Here are four questions the candidates should answer:

  • What steps will you take to reverse the opioid overdose epidemic?

  • How can you alleviate the funding strain caused by the low payment for ambulance transportation for Medicaid/Medicare patients?

  • Will you support the creation of a federal body for EMTs to increase productivity and efficiency?

  • Will you place restrictions on the price increases of common, life-saving drugs that are basic EMT requirements, such as the EpiPen?

Opioid Overdose Epidemic

Guess what? More people die from opioid overdose each year than from motor vehicle collisions! In 2014 alone, there were 47,055 deaths from drug overdose, 2/3rds from opioids. The opioid overdose epidemic should be a big concern for anyone considering EMT training, because opioid addicts are highly likely to be repeat patients.

EMT's responding to an opioid overdose use Naloxene a synthetic drug, similar to morphine, that blocks opiate receptors in the nervous system and can reverse the effects of opioid overdoses. But because the use of naloxone has skyrocketed together with the rate of overdoses, the price, once about a dollar per dose, has increased by 1000% or more, adding more strain to the underfunded EMS system. Repeat patients and overpriced medicines all contribute to reduced EMT salaries.

What a future president can do:

  • Institute strict legislation on the administration of OxyContin (oxycodone).

    Why? Until the mid 1990's, opioids were used only for patients with truly significant chronic pain, such as cancer patients. Then OxyContin came onto the market. And the creators of OxyContin downplayed the addictive qualities of the drug and marketed it aggressively to doctors. Money is the be all and end all, right? The result? An increase in sales of OxyContin from $45 million in the first year to nearly $3 billion a decade later – along with an equally severe increase in addiction, overdose and death from opioids.
    There are already several models of drug restriction the federal government can follow. In Pennsylvania, for example, there is a strict limit on the number of opioids a patient can receive after an ER visit. There is also an electronic prescription drug monitoring program that allows prescribers of controlled substances to prevent patients from going from doctor to doctor to get more opioid prescriptions. By placing similar federal guidelines on the use of oxycodone as a pain reliever, the next president could be preventing hundreds of thousands of innocent patients from inadvertently becoming opioid addicts.

  • Mandating long-term intervention for any patient brought in for an opioid overdose.

    When a patient is brought in for major trauma from a car accident, vast resources are invested to reduce the rate of death and disability from their injuries. A severely injured accident victim will probably spend weeks in the hospital and then rehab. What resources are invested into opioid overdose patients? A short period of observation and then a discharge right back into the environment that caused them to overdose to begin with! There are better ways. In Toms River, NJ, the RWJ Barnabas Health system created a program where recovery specialists are sent to Emergency Rooms whenever an opioid overdose patient is admitted. The specialists offers the patient immediate access to an inpatient recovery unit or up to eight weeks of long-term follow-up in the community. The Barnabas Health IFP program has seen its success rate of getting addicts into recovery rise from 20% of patients to 80%.

Therefore, the next president can encourage legislation requiring:
a) Recover specialists on site in every emergency room
b) A mandatory admission to an addiction recovery unit for any overdose patient

Insufficient Ambulance Reimbursement for Medicaid/Medicare Patients

There are several problems with the current mode of payment by Medicaid and Medicare for ambulance transport.

  • The fact is that the insurance coverage provided by Medicare and Medicaid for ambulance transport does not cover the cost of service – and these patients account for more than three quarters of all ambulance transport patients.

  • EMS agencies do not get paid for the cost of medical care delivered to patients who decline transport to the hospital. The result? EMS agencies have an incentive to transport all patients to the hospital, even if unnecessary, so at least some of their costs get reimbursed.

At the moment, this shortfall is usually addressed by subsidies from local governments. But this is not a long term solution. The next president must set up some sort of federal funding for EMS systems so they can continue to operate in an efficient manner.

Creating a Federal Body for EMS Services

When it comes to national disasters such as major terror attacks, or virus epidemics, the local EMS service model doesn't work very well. Because there is not central body to coordinate, it is hard for EMS from different locations to work well together. In addition, if the data from all the EMS agencies was consolidated, it would allow for better national disease surveillance and national disease prevention programs. The formation of a single Federal "home" for EMS would promote equipment standardization, national emergency response coordination, and central training guidelines. It would allow EMS to improve our EMS system's ability to respond daily and during disasters.
Will the next president make this a priority?

Overpriced Drugs

Yes, there are alternatives to the EpiPen. But, come on – they aren't truly solutions.
Imagine entering your child's school nurse office and finding a collection of generic medical supplies – syringes and vials – rather than a stock of neatly-packaged EpiPens. Which makes you feel more secure?

Auto injectors are easy to store, easy to use, and don't require much training. Other injection methods are a lot messier – but that is what EMTs are using these days as the price of EpiPens skyrocketed. Why? Well, "because it's cheaper". Should that be a reason for potentially endangering patients?

The same applies to the sharp price rise in Naloxine. The next president needs to institute some federal guidelines restricting the unnecessary price rise of lifesaving drugs.

EMT's and Crime Scenes

The streets are buzzing with talk of the recent New York and New Jersey bombings and the arrest of the suspect, Ahmad Khan Rahami.

Now what does this have to do with an EMT blog?
A lot
Take this excerpt from a New York Times article:

"Mr. Rahami, blood pouring from a wound in his shoulder and splattered on his face, was loaded onto a stretcher and taken to University Hospital in Newark."

This is just one of the many instances when emergency medical care and the criminal justice system collide. You may shy away at the thought – treating a deadly criminal? Why should you waste your energy, skills, and good medical equipment, on a man who tries to kill?

But the truth is, by saving a criminal's life, you may be helping his victims. And in a case such as this, where it is an act of terror, you may play a role in preventing similar incidents in the future. If the criminal is alive and in stable condition, he can be questioned by law enforcement agencies and the court. The information they gain through this is usually highly valuable.

Approaching a Crime Scene

When you approach the crime scene, as an EMT, your job remains the same – to save lives and give appropriate medical care. However, there are several other things you'll need to be aware of.

1) Don't Become a Victim!
Before anything, you need to make sure that you are not in danger of becoming a victim yourself. Unless you were trained as a tactical EMT, you are not required to enter a "hot" or "warm" zone (where there is still active violence or a chance of violence.)
Only once the scene was given the all-clear and the criminal is neutralized should you enter and begin triage and treatment.

2) Be Aware
The patient was lying on the couch? Take note. You moved a table to get to him? Remember where it was originally.
In one instance, investigators wasted a lot of time because they thought a witness had moved things around after the crime. In reality, the paramedic had moved some items to gain access to the victim, but had not informed anyone of this. (Journal of Emergency Medical Services, Crime Scenes: Documenting Assessment and management of crime victims.)

3) Document Everything
You may be so preoccupied with giving care that you give just a perfunctory documentation of the event. Don't do that.
Especially if you were one of the first at the scene, chances are, you'll be called in as a witness. In addition, because the defense will be looking for a way to get the criminal off the hook, they can even try to shift the blame onto you!
So make sure you recall every detail and document it as soon as you can. Especially take note of anything you moved on or near the patient's body, anything the patient or bystanders say to you, and what treatments you administered.

4) Record Facts
Only write down things that are objective – not the conclusions you drew. For example, don't write if it was a knife or bullet wound; just describe the way the wound looked. Don't identify a person as "intoxicated"; just describe his behavior and the smell of his breath. Leave the conclusions to the court.

You may feel that EMT's are not police – and you're right. Your primary responsibility as an EMT will always be to care for your patients. But by coming to the rescue at a crime scene and following protocol, you can help the truth be uncovered and play a vital role in assisting victims beyond their medical needs.

What Do Certified EMT's Really Do?

EMT's drive ambulances, right?
Wrong.

Though many EMT's do work responding to emergencies by driving an ambulance, the truth is that there are quite a few career paths you may take using your EMT certification.

  • Transfer Service Driver/Attendant

    You don't do well under pressure? This may be the job for you. Unlike standard ambulances, the patients using transfer services are not in an emergency situation. Transfer services transport patients from one facility to another. For example, if an elderly woman using an oxygen tank needs to travel from Connecticut to Manhattan to see a specialist, she would use a transfer service.
    Average Annual Salary: $$29,614

  • ER Technician

    Hospitals always fascinated you? You can get to work there, even without attending medical school. Though you may need to get some extra training (i.e. phlebotomy certification), EMT's can work in the Emergency Room doing tasks such as:

    1) Helping with patient care
    2) Moving patients
    3) Assisting nurses
    4) Checking vital signs
    5) Starting IVs and drawing blood

  • Firefighter

    As the recent wildfire in Alberta proves, firefighters are vital to protecting communities and nature. In 1849 and 1850, the new city of San Francisco burned down six times! Why? There were no firefighters. If not for firefighters, the countless minor fires that flare up every day would easily consume entire cities. As a firefighter, you would be playing a huge role in keeping people safe. In addition to that, firefighters receive a nice salary, benefits and something worth a lot more than a large salary – job security. By signing up for your EMT certification, you'd be taking your first step towards becoming a firefighter.
    Average Annual Salary: $42,250

  • Rescue work Every year, communities all over the world suffer from devastating natural disasters, often leaving many people trapped in dangerous locations. As an EMT, you would be able to join the heroic search and rescue teams that help bring people to safety.
    Average salary is: $41,000

  • Stand-by Medical Team for Events Want to get free entry to all the baseball games? Your EMT certification can get you there! Most large events such as baseball games are required to have EMT's and medics on site in case of emergencies. Although this is usually not a full time job, it can be a great choice to earn some extra money while in college.
    Average Salary: $15/hour

  • Medical Assistant Although you may need extra training to work as a medical assistant, some private doctor's offices and clinics employ EMTs as assistants, as they have the necessary medical knowledge.

  • CPR/First Aid Instructors

    Do you enjoy teaching? You can combine this with your love of saving lives as a first aid instructor. Not only that – you'll be making the world a safer place as you keep passing on life-saving medical knowledge to your students.
    Average Annual Salary: $33,000

  • None of these careers appeal to you? No reason to pass on becoming an EMT. EMT certification give great background and can be a stepping stone to other careers such as:

     •   Paramedics
     •   Medical school – most medical schools require volunteer field work. Becoming a  certified EMT give you many      opportunities for appropriate community volunteer  work in the field of medicine.
     •  Nursing school
     •   Physician assistant
     •   Emergency Management

Getting EMT certification can open up so many doors for you. Take the first step and sign up for a course, and begin walking towards your future today!

Becoming an EMT... What's it about?

Ronald Reagan said, "Those who say that we're in a time when there are no heroes, they just don't know where to look."

Because heroes can be found in the most ordinary of places – such as the ambulance that just drove by with wailing sirens. Who's the hero in there? The EMT.

Though saving lives ranks pretty high up there in "heroic acts", becoming an EMT ranks quite low in difficulty.

You don't even need a high school diploma. Or even a GED. If you're 18 and reading this blog, you're a candidate. In just 3 to 5 months, you can be an EMT eligible to receive an EMT salary.

Who's a good candidate to become an EMT?

You already work full time? You're a student? No worries – Emergency Care Program's EMT courses are offered with varying schedules to accommodate many lifestyles. You already have other career plans? EMT certification can be a big asset in many careers. For example, the FDNY hires many EMTs. Or if you always dreamed of becoming a doctor, but.... You don't have to give up on your dreams. Working as an Emergency Medical Technician will put you right in the thick of things, seeing and doing and being part of the action.

How does the course work?

Sitting through classes bores you to tears? Then this course is just the place for you. Though of course you'll need to listen to some lectures, a large part of the course is practical and hands-on. And the best part? A 12 hour rotation in a real-life hospital emergency room.

After passing the practical and written examinations, you'll take an NYS EMT-Basic Certification exam.

What will you learn?

Everything you need to know to take charge at the scene of a medical emergency. The next time something happens that throws everyone into chaos – you'll be the one taking charge.

You'll learn about:
• Patient assessment
• Trauma care
• Managing medical emergencies
• Utilizing Basic Life Support equipment
• CPR
• Hemorrhage control
• Fracture and spinal stabilization
• Managing environmental emergencies
• Emergency childbirth
• Use of a semi-automatic defibrillator

How much does it cost?

For the competitive price of $1250, you get the full course, including all required equipment – blood pressure cuff, stethoscope and CPR mask. (Textbooks will be purchased separately.) We also offer payment plans to spread out the cost.

Why choose a career as an EMT?

It's not everyone who can say that they spend their days saving human lives. And even when you aren't saving a life, you'll still be touching countless lives in a positive way. A small boy broke his arm? You'll comfort him and tell him how it's not so scary. A lovely older woman is having a stroke? You'll be reassuring her and getting her to the hospital before the clot causes irreparable damage.

And, yes, when someone's heart has stopped, you can bring them back to life with CPR.

Saving lives and helping others while making money - who can say no to that?