Category Archives: Rescues

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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Filed under Conferences, EMS Health & Safety, EMS Topics, Fire Rescue Topics, Firefighter Safety & Health, News, Opinion, Patient Management, Rescues, Technology & Communications, Training & Development

High Speed Education Where Eagles Gather

Dallas is the place to gather today and tomorrow if you are like me and actually enjoy the most current thinking on pre-hospital medical practice coming at you like a fire hose from the very “eaglesâ€? of our business. Unfortunately, I am not there. Instead, I was standing a thousand miles away this morning in a dim light hallway peering into a bedroom where a large chested man had been pulled from his bed onto the floor and was surrounded by a team of EMS professionals efficiently working to bring him back to life. The call was a mutual-aid assistance request from a neighboring district and I was one of a handful of “trained providersâ€? simply waiting my turn to begin compressions. We haven’t justified the money in my county for mechanical CPR devices.

At the Gathering of Eagles conference in Dallas, the first lightning round of topics for this morning was scheduled as “Resuscitating Resuscitation: New Technologies and Approaches for Achieving ROSCâ€?. I wished desperately that I could have been walking down a hallway in that Texas hotel instead of standing in that local house between a husband and his wife.

Still, no matter where I am, I try to take in all the information I can and learn something from it. Here, I was limited to watching each fresh new rescuer dutifully assume the position for compressing our patient’s chest. Why is the room always so small? The bed is always so close and the personal effects of a lifetime are always stacked neatly in the way. Worst of all, the patient never seems to resemble the size of the mannequins we use in practice. But what struck me most vividly this morning was watching the inconsistencies between each of these well-meaning rescuers. I even started a checklist in my mind of the failures I saw. It was that attitude that led to the most important failure, it was the fact that I could almost viscerally feel a lack of hope in that room.

Also lacking in the setting was anything to keep cadence for the compressions or the rescue breaths. The eagles were about to tell me that without a metronome, providers typically compress too fast. I saw exactly what they discovered, that rescuers could routinely hit a rate as high as 140 compressions per minute even though we know we need to stay in the range of 115 to 120. The idea that “more is not betterâ€? is quite clear here and we need to build better muscle memory. I knew we were being good about limiting the pauses, but I would soon be reminded that our enemy is not that “we suckâ€?, but that we are satisfied that we are doing “good enough.â€? I learned from the Resuscitation Academy at EMS Today last year of the importance of going into every OHCA with the attitude that “everyone survives.â€? However, my faith somehow still gets robbed.

In just a few hours, I would be reading notes from attendees in Dallas promoting the virtue of consistency in providing “world-class manual CPR.â€? But at that moment, I didn’t feel surrounded by “eagles.â€? The Eagles would tell us about places like Oklahoma City and Tulsa that use the “pit crewâ€? approach so everyone knows what they are doing. We’ve got that in place here when it comes to pushing drugs and managing airways, but the prevailing opinion here is still that compressions are just a brute force task to manually maintain circulation through the heart. I would also hear that Memphis, where each ambulance is equipped with a LUCAS device, is getting ROSC in 30% of arrests compared to 21% of arrests employing manual CPR. Probably the same type of CPR that we were performing today.

What we needed to hear was more than just advice to minimize compression pauses, to slow them down, maintain compressions even while the AED is charging, and always remember the fundamentals! We needed the advice that helps us recognize that PEA is a health hazard when it is distracting us from focusing on compressions by spending too much time looking for that elusive pulse. I needed to know that only 15% of pulse checks are accurate when done within the AHA guideline of 10 seconds or that if you don’t have VF, even the AED can be a health hazard due to prolonged compression pauses for rhythm analysis.

We all need to be convinced that with the advent of LUCAS/ITD and easily applied ECMO/LVAD, we may not need to care as much about the condition of the heart as we should be concerned over the resuscitation of the brain. The Eagles are further suggesting that traditional “supine CPRâ€? should soon become a thing of the past in favor of a 30-degree “heads-up” Gravity-Assisted CPR that promises to improve patient outcomes. As they explained today, standard CPR increases ICP and facilitates only low cerebral perfusion pressure. A trend which is reversed by elevating the patient’s head up 30 degrees. We can also hope that someday we can be using ultrasound in the prehospital setting to determine optimal position of chest compressions. And it’s not just compressions that need our attention, but to understand that positive pressure assisted ventilation actually decrease the coronary perfusion pressure.

What I learned today in both of the settings where I found myself is that there is no “silver bullet.” There is still much to learn and understand and it is only hard work and an interest to do better that will ultimately ensure a future where everyone will have a better chance at survival!

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Trauma Shears Dilemma

I started out with the basic trauma shears that cost only a couple of dollars, but soon realized I wanted something a little more “substantial” and upgraded to the basic titanium shears I currently carry. They do the job adequately, but there are some other interesting options out there and I am looking for some reasoned opinions (or Christmas present suggestions.)

I am impressed by the Leatherman Raptor that can be purchased for around $60 here in the US. They would be like my own little “Transformer” riding it’s very own holster on my belt. However, I have to admit that I kinda fear being seen as a “wacker” with it.

Then there is the RipShears for only about $25 (or a couple extra for the “glow-in-the-dark” version.) These seem very sound with a great track record (and fewer moving parts) but maybe a little bulky.

Both add features like an O2 wench (or window punch or reflex hammer…) but honestly is that necessary? What is your experience or advice?

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Filed under EMS Topics, Opinion, Rescues, Videos

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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The Role of Response Time in EMS Performance

Several months ago, Rob Lawrence of the Richmond Ambulance Authority started a thread on the High Performance EMS Group of LinkedIn by asking “So what does the phrase ‘High Performance EMS’ mean to you?â€? This innocent sounding question sparked immediate debate even within the small group at that time. Benjamin Podsiadlo of AMR quickly tied the quality of EMS performance to “experienceâ€? and “outcomesâ€? stating further that “response time is not an evidence based factor in ALS performance.â€? He later backed up his assertion by writing that “the catch 22 of pushing the workforce to be responsible and accountable drivers while simultaneously achieving narrow response time goals to the vast majority incidents that have no medical need for such high speed driving is also a bizarre and irresponsible contradiction.â€? This is a point that even Lawrence admits could foster the “mentality of ‘arrive on time and the patient dies – good outcome, arrive late and the patient lives – bad outcome’â€? that has already been affecting common sense both in the UK and increasingly in the US since NFPA 1710 set response time standards several years ago.

While there were other good comments, I would like to focus on the specific assertion that measuring response time (a well established practice today such as at Huron Valley Ambulance’s public web Performance Dashboard) is not an “evidence-basedâ€? practice. There are many specific accounts of individual lives saved that I have heard mentioned by different agencies, but I will concede that the plural of “anecdoteâ€? is not “dataâ€?. However, one of the best stories of response time saving lives was made on February 9 when Richard Sposa of Jersey City Medical Center EMS discussed an interesting finding in a recent webcast. The chart reproduced here shows a correlation between

Return of Spontaneous Circulation vs. Response Time

response time and the Return of Spontaneous Circulation (ROSC). This unexpected finding clearly traced an upward trend of ROSC with the decline in Average Response Time for Priority 1 Calls graphed quarterly from the beginning of 2005 to the end of 2007. This is a verified statistical trend (Mount Sinai Hospital reviewed these findings) and I suggest you click to view the graph in full detail. This shows not just living anecdotes, but a statistical increase patients with restored heartbeats.

Many things about our business can and should be questioned, but this is exactly the sort of evidence I would like to see investigated at other services. Can what Jersey City Medical Center is experiencing be reproduced elsewhere? And probably more importantly, does fast response necessarily mean “high speed drivingâ€??

The point of System Status Management (SSM) is that ambulances can be effectively pre-positioned through scientific statistical forecasting in order to reduce the time of a response even without driving faster to the call.  Zoll Software Solutions, as an example, considers the elimination of inefficiencies to be a core component for closing the loop on your dispatch process and is even offering free medical equipment to customers who use this technology to improve their system. One customer who has done this already with Zoll technology is Grand Rapids who was also featured in the following FOX News video on Predicting Where your Next Emergency will Happen.

If you believe that knowing where your next calls are likely to come from in time to allow you to safely prepare for that response, the science is available today. You just need to be able to integrate that knowledge into your process.

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Filed under Dispatch & Communications, EMS Dispatch, EMS Topics, Opinion, Rescues, Technology & Communications, Uncategorized, Vehicle Operation & Ambulances