Category Archives: Fire Rescue Topics

Better Lifting for Better Care

Anyone who has been to a national EMS conference in the last few years has probably seen Rick Binder in the exhibit hall. If that name is not familiar, you may be more likely to remember his life-size teddy bear wearing a vinyl vest surrounded with brightly colored handles. While we are friends now, I have absolutely no financial interest to disclaim. In fact, I had initially avoided both him and the product that his dad had developed whenever I saw the booth at trade shows. Personally, I just didn’t see the need for it since I was a master with a hospital sheet and had acquired a wide repertoire in the many ways to use it. But there are times that peer pressure can be a good thing. Other teammates from my service had visited with him at EMS Today and appeared to be impressed. Curiosity got the better of me and I wanted to learn what I might have overlooked, so I took Rick up on his free offer to field test the device. It was because of my own experience with the Binder Lift that I was finally sold.

I have learned that there are many lifting situations where this device will be an incredible asset to me as well as my patients. The slogan, “because people don’t come with handles” initially led me to think that the use of the Binder Lift was directed primarily at the bariatric patient who requires only a simple lift assist to return them to an upright condition where they can sign my refusal form. While it is certainly useful in such cases, it is definitely not limited only to that situation.

In my first example of these many unique cases, the patient was over six-foot-tall and had been discovered unconscious, but breathing, on his front porch by a third-party caller. I had been to that address before and knew he had a history of stroke that had previously left him unable to drive. We had three responders available and knew we needed to get him to the hospital quickly. After a rapid initial assessment, the patient was rolled to his side so we could apply the Binder Lift. Once secured, one person grabbed his feet while my partner and I were able to grab different handles to balance our height difference and eased his lanky frame down the steps to our stretcher. This movement was much easier on our backs and proved safer for the patient compared to our other options that day.

The simplicity with which we were able to transport this patient made me think back to a previous visit here. I only wish I had had this device when this same patient had been helping his elderly father get to the bathroom toilet. I can only imagine the mishap that led to his naked father falling on top of him – pinning him to the bath tub wall. Then, whether it was due to the fall or just the wait for us to arrive, his dad had defecated quite a lot. The waste had eventually made its way over both of the men. Finding a firm handhold on the slippery gentleman was a challenge made even more difficult by his son being entrapped beneath him. The vinyl construction of the Binder Lift would have made the extrication job much easier to accomplish and also simpler to clean up afterwards. It may have even prevented the need to change my uniform that evening.

In another memorable example, it was about 2AM when the tones dropped for a fall with injury. The husband of a 62-year-old female found his wife on the ground in front of their porch. She had stumbled and fallen forward about a two-foot drop. Unfortunately, she had braced herself for the landing with a stiff arm before reaching the ground. Her primary complaint was pain in the right shoulder which, although closed, did exhibit deformation (a probable dislocation. She denied any other pain along her spine, but as a precaution against a distracting injury, we placed her in a cervical collar per protocol.) Getting the patient to a seated position was accomplished only with significant coaxing and some obvious pain. There was no option of lifting her from beneath her arms and her loose pajamas gave little hope of bearing the weight of her hips to lift her. So after placing her right arm in a sling, we were able to place the Binder Lift around her torso and helped her move her legs into a crouched position without any further aggravation. The patient was then easily lifted upright and the stretcher maneuvered behind her allowing her to simply sit down. The Binder Lift was also helpful in orienting her on the cot. Finally, the slick vinyl material of the vest and straps was easily removed to leave her comfortably in a high Fowler’s position on the stretcher.

In short, the Binder Lift allows for better body mechanics when lifting that not only help to raise the patient safely but can be effective in extending the careers of medics that might otherwise be forced into premature retirement due to back injury. If you don’t try a Binder Lift for your patients, at least do it for yourself. I still carry an extra hospital sheet for many situations, but it always lays right on top of my Binder Lift.

Learn more at http://binderlift.com.

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Christmas Responders

A special Christmas poem for first responders…

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EMS Today 2018 Highlights

The EMS Today conference is always filled with interesting content both in the classrooms as well as the show floor. My live Twitter feed during the conference referenced highlights of the educational sessions I attended ranging from the Operational category to Advanced practice and even some Basic courses. The complete experience shared by everyone is permanently archived with the official #EMSToday hashtag. 

I traveled the exhibit hall several times last month looking for innovative and practice-changing technology. There was plenty to be found and the “best” will always be subjective. While these are some that I felt were worth sharing, others may have found significant gems I missed. If you were also there, please feel free to use the comment section below to add your own impressions of what you see as important in changing the practice of our field of EMS. 

One of my favorite sessions at any national EMS conference is when you can find a gathering of even a small number of “Eagles” (the top Medical Directors from around the country.) The lightning round of “The Eagles Unplugged” presentations in Charlotte was on February 22, just a week before the huge international Gathering of Eagles in Dallas. One of the first topics requested by the audience was on “spinal immobilization” (or in deference to my friend Rommie Duckworth, the proper term should arguably be “spinal stabilization”.) There was certainly no love in that packed room for most techniques or devices currently in use. In fact, the emphatic consensus statement was that there is simply no literature that shows any benefit to current spinal motion restriction while there are plenty of documented complications. 

In regards to spinal stabilization, everyone in the room agreed that the long spine board is gone and immobilization currently consists of just a collar. However, there was no consensus on what that collar should look like while there was no shortage of complaints for what is currently on the market. One of the JEMS “Hot Products” from EMS Today in 2017, however, was the SIPQuik vacuum cervical splint from Care 2 Innovations which I only got to play with this year. Basically, it is a collar-shaped bag filled with tiny styrofoam beads and a generous velcro strap. It has several advantages in that it fits a wide variety of patients and will conform closely to the shape of the neck to provide gentle support in any position. Unlike rigid collars that require the head to be placed in the neutral position for stabilization, the SIPQuik can wrap around the neck and be secured comfortably snug with the strap before the collar is molded to support the head while the air is vacuumed from the collar. The beads are held tightly in place to provide support that minimizes the possibility of further injury. Removing the manual pump without locking the air tube will allow air to reinflate the collar for easy removal. 

Several sessions, and exhibitors, included discussions of safety for care providers while working on the road. In America, we tend to love the large square box we call the patient compartment in our Type I and Type III transport vehicles. The size of the box and position of supplies and equipment requires a significant range of motion and most providers roam about unrestrained. Traditional safety belts are already available in every seat, however, they are just too cumbersome to apply and too restrictive to be used. At least this was my thinking until I placed by arms into the new 6-point “Back Pack” belting system on the EVS2160BPB from Emergency Vehicle Seating, Ltd. Unfortunately, the Back Pack system is not advertised on their website yet, but if you are interested, they will know what you are asking about if you contact them. 

The shoulder straps were as easy to apply as simply slipping my arms through the loops.  But the range of motion was incredible and allowed me to stand up fully and reach clear across my imaginary patient to where I would expect cabinets to be on the other side of the room – while still wearing the shoulder straps and even the lap belt! As I return to the seat the straps automatically tighten and should the vehicle have an accident, the belts would immediately tighten to prevent my head from crashing into those same cabinets across my patient. This quick and easy seat belt access is certified to meet all safety standards of FMVSS and SAE while providing maximum flexibility for the care of my patient. Two EVS1790 captain’s style chairs in place of the typical bench seat also allows comfortable and safe crew seating or can be rotated and tilted forward to allow the transport of a second patient on the non-skid back surface of the seats. Clearly, EVS has been giving plenty of thought to where we put our butts.

Another one of the hottest topics in prehospital treatment of trauma has to be the use of tourniquets and binders. I really thought that the poplar military-style tourniquet had not changed significantly from the belt and windlass configuration of decades ago, but there have been innovations here as well.

The S.T.A.T. Tourniquet is probably the greatest revolution in design. It comes in both a pediatric and adult size, but immediately conjures up the ubiquitous zip tie. It is wrapped around the limb above the injury and the end is inserted and pulled as tight as needed (in 2mm increments) to easily adjust. Although it looks like a zip tie, it is anything but what you find in the hardware store however. It is a wider design to prevent cutting into the skin and the material is a stretchier rubber to hold fast and evenly to secure blood flow. It also has a simple timer that can be activated when applied to measure half hour increments up to a max of 2 hours. Like the common zip tie it resembles, it can be used in combination to create a larger band or used in a series for splinting too. One major difference from the traditional zip tie is that this model also has a release tab to remove the tension. The simple design and lower cost compared to a traditional windlass system makes it ideal for public use in an MCI situation as part of a hemorrhage control kit. S.T.A.T. Medical Devices even sells them preloaded on a carabiner in a quantity of 25 tear-off tourniquets.

 

In case that style of tourniquet design is just too revolutionary, the folks over at SAM Medical have evolved the traditional tourniquet design by adding TRUFORCE Buckle technology to auto-lock the tourniquet during application. Slack in the tourniquet is the main cause of application failure requiring extra time twisting the windlass or even restarting the application. The SAM XT is designed to

require 33 pounds of force to engage two pegs that hold the strap before it is Velcro-ed together and the windlass can be engaged to stop the bleeding. This makes application easier and quicker. They also have a junctional tourniquet to stop pelvic hemorrhage. And my favorite model is the SAM Pelvic Sling II to comfortably apply the correct force to stabilize pelvic fractures. The design looks similar to the SAM XT tourniquet, but uses a patented AUTOSTOP buckle instead that ensures that the optimal compressive force is reached to confirm correct application. It is more expensive than a hospital sheet, but it provides confidence and comfort in a professional design.

I was also impressed by the Water-Jel Burn Dressings which provides a cooling gel (that is water-based, bacteriostatic and biodegradable) that actually stops the burn progression by actively cooling the skin and relieving pain rather than simply covering the wound to protect against airborne contamination. These dressings come in several different sizes and have a shelf-life of 5 years. The other great feature of these dressing is that each dressing has a Total Body Surface Area (TBSA) icon that indicates approximate total body surface area covered with the use of that particular dressing to improve your estimates of the body area covered.

Finally, to reduce medication calculation errors in pediatric patients, CertaDose provides syringes printed with color bands that match the Broselow tape used with younger patients. These syringes are clinically proven to reduce critical dosing errors by labeling the correct dosage directed on syringes labeled by the medication to be administered. Simply select the correct drug, match the color zones according to the Broselow tape and draw up the correct dosage.

I should also mention StethoSafe as another highlight from the floor of the show because I rely on their product to protect my stethoscope, but I did a whole other blog on the StethoSafe earlier.

Leave a note about what you found most interesting.

 

 

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Fore Thoughts of EMS Today 2015

For the last few years I have written my initial impressions of conferences in blog posts shortly after, or sometimes even during, a conference. The post “Quick Thoughts from the EMS Today 2012 Conference,” for instance, described my first EMS Today experience and captured the fact that I actually had the opportunity to give ‘two thumbs up‘ to my boyhood idle ‘Johnny Gage’ (aka Randolph Mantooth) among other professional icons. I also had the opportunity to ride along with a BCFD crew and documented that experience in the post “A Country EMS in the Big City” that year. The next year, I got to experience EMS Today in DC along with the much hyped ‘Snowquester‘ that abbreviated the EMS on the Hill advocacy opportunity, but where I did still get to witness a small ‘Gathering of Eagles‘ slaughtering a number of ‘sacred cows.’ A summary of that experience is recorded in the post “Quick Thoughts from EMS Today 2013 Conference.” Last year provided a very different perspective as I got to document EMS Today from the viewpoint of a pre-conference presenter and spent much of my time as an exhibitor on the show floor. One of my favorite learning experiences, however, was the ‘Resuscitation Academy‘. Some of my experience that year was covered in the post “Quick Thoughts from EMS Today 2014.” But this particular post is a unique first, as I am writing this time about a conference that hasn’t even happened yet – EMS Today 2015!

My interest in this coming conference is as a blog reporter. I hope to attend this conference as an official blogger tasked with documenting once again my experience as a participant in all of the fascinating aspects of this powerful and educationally-packed conference. If you are planning to attend the conference, we can help each other. Your registration using the code ‘EMSBDALE’ gets you a discount, even beyond the early bird discount rate, and provides a vote of confidence in me to be selected as the official blogger for this coming event. To make it an even better deal for you, each registration using my code will be entered into a drawing for a mini Apple iPad this month and another for anyone who enters my code during registration for January as well.

I hope that you do get to go to this keystone EMS event and that you will help me get there as well. If we do win, you will hear about it first on this blog page. PennWell and JEMS is working closer with its Fire EMS blog network than ever before in order to bring you a more intimate view of the conference and the larger industry of EMS as well through independent blogs, Facebook pages like High Performance EMS, and Twitter feeds including @hp_ems. So even if you don’t get to the 2015 EMS event of the year, you can still experience some of the excitement and continue to learn all throughout the year.

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We Need Some New Stories

We always hear that EMS is still a relatively new discipline. And in the scheme of medicine, or even public safety, that is certainly true. But we shouldn’t let the fact of its youth keep us from acknowledging that it has already been around long enough to accumulate some of its very own antiquated dogma. If you have any doubt, consider the reaction to changes in protocol – even those with good evidence to support some new practice. Working cardiac arrests on scene, for instance, was not met, at least in my experience, with enthusiasm at the prospect of improving patient outcomes. What I heard were excuses for why something different wouldn’t work. I thought about that exchange this week as I was listening to a recent Medicast podcast on an entirely different topic. Near the end of that recording, Rob Lawrence remarked that we really need to do away with the old stories that start out with “back in my day…”

The stories of some grizzled professionals include not just memories of MAST pants or nitrous oxide, but the idea that tourniquets take limbs, not save lives. More recently stories have been spun about the movement away from the long-held reliance on the long spine board as an immobilization splint during transport or even the value of therapeutic hypothermia for cardiac arrests.

While there is no denying, or even stopping, a rapid state of change in EMS, we must be sure that it is not just change simply for the sake of change or even resistance for the same reason. Change must be meaningful change that is guided by reasoned thought and scientific evidence, not personal anecdote. And new practices should be carefully modified to address current issues or new understandings of the problem.

Another sacred, yet unjustified, belief among too many providers is that the dynamic deployment of resources (commonly referred to as “SSM”, or System Status Management) is an unmitigated failure of cost-consciousness that actually leads to increased expenses and provider dissatisfaction. The evidence, however, from many of the services who now employ some facet of dynamic deployment has proven that while it can be tricky to implement well; the savings in time, money, and lives are definitely real. And those savings need not come at the cost of provider safety or comfort either. Whether you have had bad experiences in the past, or just heard about it from others, it is time to set aside the old stories and take a new look at the current technology and practice in every aspect of EMS that leads to improved performance.

To advance our profession, we must completely ban the expression,  “but that’s how we’ve always done it” and look toward “how we can do it now!”

 

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How To Perform CPR: The Crucial Steps You Should Know (and Share!)

This important article (and the associated graphics) is reprinted as a guest blog with permission from Monica Gomez, a freelance health and healthcare writer. Originally published at http://carrington.edu/blog/medical/how-to-perform-cpr/.  The animated GIF images alone are worth sharing!

Anybody can and anybody should learn how to perform CPR (Cardiopulmonary resuscitation): According to the American Heart Association, a stunning 70% of Americans don’t know how what to do if somebody is experiencing a cardiac emergency because they don’t know how to administer CPR or they forgot the exact technique. This is especially alarming since almost 90% of cardiac arrests occur at home — where patients depend on the immediate respiratory care response of their family members. In brief, knowing how to perform CPR can save the life of a loved one someday. CPR-How-To CPR-How-To-AdultsCPR-How-To-ChildrenCPR-Cats-and-Dogs

While 400,000 cardiac arrests happen outside of hospitals each year in the U.S. alone, hands-on CPR can actually double or triple an adult’s chance of survival. However, you need to act quickly. At four minutes without oxygen, the patient will suffer from permanent brain damage. At eight to ten minutes, the patient can die. Almost 90% of cardiac arrest patients die because no one performed CPR at the scene.

Before You Start CPR

First of all, check if the patient can respond by tapping them on the shoulder and shouting “Are you okay?� If they don’t respond, call for medical emergency services immediately. If others are around, instruct them to call 911 and if you’re alone, do it yourself. If the patient is an animal, call the closest animal hospital. If you happen to be near an AED (defibrillator), read the instructions and give one shock to the patient (this applies to humans only).

CPR Steps For Adults and Children 9 and Older: Hands-Only CPR

  1. Lay the patient on their back and kneel next to their neck and shoulders.
  2. Place the heel of one hand on the center of the patient’s chest.
  3. Place the heel of your other hand over the first and lace fingers together.
  4. Keep your elbows straight and align your shoulders directly over your hands.
  5. Begin compression:
  • As hard as possible
  • At least 100x/minute
  • Allow the chest to rise fully between compressions.

TIP: Give compressions to the beat of disco hit “Stayin’ Alive�!

CPR Steps For Younger Children and Infants

  1.  Tilt the head back a bit and lift chin to open the airway and check for breathing.
  2. If there’s no breathing, give either of these two rescue breaths:
  • Child: Pinch the nose shut and make a complete seal over their mouth
  • Infant: Make a complete seal over their mouth and nose.
  1. Blow in for one second, so the chest visibly rises and repeat this once.
  2. Give 30 chest compressions (100x/minute):
  • Child: Push with one or two hands about two inches deep
  • Infant: Push with two to three fingers about 1.5 inches deep.
  1. Repeat these steps three to four times.

 

Pet CPR – For Dogs and Cats

[Follow these CPR instructions for puppies]

For Animals Under 10kg/22lbs:

  1.  Use the one-handed technique, wrapping the hand over sternum and chest.
  2. Give 30 chest compressions (100-120x/minute).
  3. Allow the chest to fully recoil between compressions.
  4. Give two mouth-to-snout rescue breaths after each set of compressions (30:2).

For Medium to Giant Dogs:

  • Position the animal on its side.
  • Use the two-handed technique, placing your hands over the widest part of the chest.

For Deep, Narrow-Chested Dogs Like Greyhounds:

  • Use the two-handed technique, placing your hands directly over the heart.

For Barrel-Chested Dogs Like English Bulldogs:

Place animal on its back and use the same positioning and technique as for adult humans Whether you perform CPR on an adult, child, infant, or pets, DO NOT STOP unless:

  • The patient starts breathing
  • An EMS or another citizen responder takes over
  • An AED is ready to use
  • The scene becomes unsafe
  • You are physically incapable of continuing

Make sure to practice and/or brush up your CPR abilities today, so you’re ready to potentially save someone’s life in the future! Furthermore, if you’re interested in making it your profession to help people suffering from respiratory conditions like asthma, bronchitis, lung cancer, heart attack, stroke, chronic obstructive pulmonary disease (COPD) or sleep apnea, you should look into Carrington College’s respiratory care program. This two-year program combines classroom lectures, laboratory instruction, and clinical experience in order to prepare you to work in a variety of healthcare settings. If you’d like to assist and educate people regarding respiratory health concerns, our training program is the ideal fit for you!

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Does 'Narcan' Deserve Any Debate?

While naloxone (marketed under various trademarks including Narcan) is not a new drug, it has enjoyed some incredible news coverage recently as the “safe antidote” for opioid abuse that can bring an overdose victim back “from the dead” simply and safely with “no side effects.” The surge in its popularity is undoubtedly fueled by a growing problem of opioid drug abuse, especially in the New England states coinciding with the recent development of an intranasal administration option of naloxone. However, stories like, “A drug to stop heroin?” from the Georgetown Record that reads at least in part,

“It works like magic. Spray half-a-dose up one nostril, half up the other and you’ve saved a life”

tend to over-simply the issues involved. Sometimes it works that way, but that doesn’t mean it will every time.

During an overdose caused by opiates, (such as heroin, morphine, oxycodone, methadone, hydrocodone, codeine, Fentanyl and other prescription pain medications) the drug is released into the brain where it binds to opioid receptors. When too many of these opioids attach to receptors on the brain stem, it causes depression of the central nervous system, respiratory system, and leads to hypotension.  These conditions result in poor perfusion and can eventually lead to death. The action of naloxone is not completely understood in detail, but basically seems to displace the opioids on these receptors to reverse the depression of critical life functions. It is important to note that naloxone is only effective at displacing opioids and is therefore not effective against respiratory depression due to non-opioid drugs or illnesses affecting the CNS.  Consequently, recognition of the direct cause of respiratory distress is important in determining appropriate treatment.

Still, even when naloxone is effective at reversing CNS depression, there are conditions that the responder must be prepared to encounter as a result of this intervention. Abrupt reversal of opioid depression may result in vomiting, hypo/hypertension, seizures, VTach/VFib, cardiac arrest, pulmonary edema, severe headaches, severe anxiety, and confusion, not to mention the severe agitation brought about when the patient loses the euphoric feeling often sought from the opioid. There is a safety concern for the “rescuer” in addition to a concern whether non-medically trained personnel can adequately perform the physical assessment of the patient required to ensure the condition hasn’t been misdiagnosed. It appears true that naloxone will not directly hurt patients who are not suffering opioid overdose, but the time delay in proper treatment could be detrimental.

There is frustration on the part of families and even communities afflicted by chronic drug abuse because action is not being taken “fast enough” when the “miracle drug” is known and available. Articles such as, “Massachusetts Police can carry Narcan, but not use it“, where it is reported that even though the state has authorized its use there are still local policy restrictions that prevent officers from administering it, seem like petty politics, or possibly even conspiratorial. I do not advocate undue or burdensome restrictions, but rather welcome a healthy dialog to help all would-be rescuers to understand the ramifications of taking certain actions. I want more equipped professionals to have access to the treatment along with tools such as suction devices, BVM, and an AED to handle possible outcomes rather than simply trading death by one route for death by another. My position on Narcan is actually similar to that of administering CPR. While I want everyone to be prepared to do it, everyone should know something about what results from taking that action. Saving a life is an incredible feeling, but it never comes without some personal cost.

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A Short Take on Long Boards

The National Association of EMS Physicians and the American College of Surgeons Committee on Trauma have made their Position Statement on spinal immobilization for EMS publicly available.  So, now what?

It is hard to argue with their findings:

  • Long backboards are commonly used to attempt to provide rigid spinal immobilization among emergency medical services (EMS) trauma patients.  However, the benefit of long backboards is largely unproven.
  • The long backboard can induce pain, patient agitation, and respiratory compromise.  Further, the long backboard can decrease tissue perfusion at pressure points, leading to the development of pressure ulcers.
  • Utilization of backboards for spinal immobilization during transport should be judicious, so that the potential benefits outweigh the risks.

I know that I have been torn in my own mind while strapping an octogenarian to a rigid long backboard when the only indication for such treatment was that she slipped on the floor of a rest home.  Neurologically she may appear completely intact with a normal level of consciousness (GCS of 15), no complaints of numbness, lacking any spinal deformation or distraction injury.  However, our protocols say she must be strapped to a rigid device without padding and subjected not only to the jolts of our handling, but every bump of a threshold as the stretcher is wheeled outside and then she continues to suffer the uneven pavement between the Emeritus Senior Living facility and the hospital.  If she wasn’t sore due to the fall, she will definitely feel it by the time she is seen by a physician.  I know I am protecting myself from any potential injury lawsuit, but am I really protecting my patient?

The Prehospital Emergency Care statement suggests criteria where use of a long backboard would not be indicated.  Part of that definition includes the following recommendation: Continue reading

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