1. september 2012
Always En Route At

2. Choose 11 at www.jems.com/rs

4. Choose 13 at www.jems.com/rs

5. The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
34
I Attacking Cardiac Arrest pART ii I
Feedback-driven team performance impacts survival
By Jeffrey M. Goodloe, MD, NREMT-P, FACEP; T.J. Reginald,
NREMT-P; David S. Howerton, NREMT-P; Jim O. Winham, RN,
BSN, NREMT-P; Tammy Appleby, NREMT-B
SEPTEMBER 2012 Vol. 37 No. 9
Contents
I 40
40 I Check the Rhythm I
Expert safe use of adenosine depends on patient’s cardiac status
Corey Slovis, MD, FACEP; Jared McKinney, MD; Jeremy Brywczynski,
By
MD, FAAEM
46 I gOING oUT ON A lIMB I
EMS provider becomes patient
By Steve Berry
52 I From the School to the Rig I
Enhance EMS preparation using the field training evaluation
program model
By Skip Kirkwood, MS, JD, NREMT-P, EFO, CEMSO
54 I MCI Magnifiers I
Many factors can complicate an incident of any size
By A.J. Heightman, MPA, EMT-P
58 I Survive Thrive I
Current goals obstacles in cardiac arrest
By Brandon Oto
Departments columns
7 I Load go I Now on JEMS.com
12 I EMS in Action I Scene of the Month
16 I From the Editor I It’s all about the Pump
60 I Deadly Dozen I
Dealing with the 12 types of thoracic injuries
By Mark Cipolle, MD, PhD; Michael Rhodes, MD; Glen Tinkoff, MD
y A.J. Heightman, MPA, EMT-P
B
18 I Letters I In Your Words
22 I Priority Traffic I News You Can Use
26 I lEADERSHIP sECTOR I First Day
y Gary Ludwig, MS, EMT-P
B
28 I Tricks OF the TRADE I Stealth Mode
y Thom Dick
B
30 I case of the month I Life Limb
y Travis Polk, MD, Carrie Sims, MD
B
32 I RESEARCH REVIEW I What Current Studies Mean to EMS
y David Page, MS, NREMT-P
B
68
71
72
74
I employment Classified Ads
I Ad Index
I Hands On I Product Reviews from Street Crews
I LAST WORD I The Ups Downs of EMS
I 30
About theFire Department and American Medical Response work in a systematic, coordiCover
Crews from Portland (Ore.)
nated manner at all resuscitations. The “pit crew” approach is proving to be a significant factor in improved
resuscitation and return of spontaneous circulation results. For more, read “Attacking Cardiac Arrest, Part II,”
pp. 34–39. Photo Kent Powlowski
Premier Media Partner of the IAFC, the IAFC EMS Section Fire-Rescue Med
005_TOC.indd 5
I 46
www.jems.com
SEPTEMBER 2012
JEMS
5
8/28/2012 9:17:07 AM

6. Choose 14 at www.jems.com/rs

7. LOAD GO
log in for EXCLUSIVE CONTENT
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This summer, EMS providers across the nation have
responded to several mass casualty incidents ranging from the
July 20 Aurora, Colo., theater shooting that killed 12 and injured
more than 60 to the Aug. 13 College Station, Texas school shooting that killed three near the Texas AM University campus.
Our hearts go out to the victims. But equally important is the
safety of the providers who respond to these types of potentially unsafe scenes. Check out JEMS.com’s major incidents
page for resources on how to be prepared to respond to mass
casualty incidents, such as active-shooter calls.
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What Makes a Good Instructor?
National Association of EMS Educators (NAEMSE) session
speaker Keith Widmeier, NREMT-P, CCEMT-P, BA, identifies
four things that make a good educator. Do you agree?
s connect.jems.com/forum/topics/what-makes-agood-instructor
Is Gun Violence a Social Disease?
Public health experts, in the wake of recent mass shootings, are calling for a fresh look at gun violence as a social
disease. What do you think?
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7

8. Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
Editor-In-Chief I A.J. Heightman, MPA, EMT-P I a.j.heightman@elsevier.com
MANAGING Editor I Jennifer Berry I je.berry@elsevier.com
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online news/blog manager I Bill Carey I bill@goforwardmedia.com
Medical Editor I Edward T. Dickinson, MD, NREMT-P, FACEP
Technical Editors
Travis Kusman, MPH, NREMT-P; Fred W. Wurster III, NREMT-P, AAS
Contributing Editor I Bryan Bledsoe, DO, FACEP, FAAEM
Editorial Department I 800/266-5367 I editor.jems@elsevier.com
art director I Liliana Estep I alildesign@me.com
Contributing illustrators
Steve Berry, NREMT-P; Paul Combs, NREMT-B
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elsevier public safety
vice president/publisher I Jeff Berend I j.berend@elsevier.com
founding editor I Keith Griffiths
founding publisher
James O. Page
(1936–2004)
Choose 16 at www.jems.com/rs
15

9. Choose 16 at www.jems.com/rs

10. JOURNAL OF EMERGENCY MEDICAL SERVICES
The
Conscience
of EMS
JOURNAL OF EMERGENCY MEDICAL SERVICES
EDITORIAL board
William K. Atkinson II, PHD, MPH, MPA, EMT-P
President Chief Executive Officer
WakeMed Health Hospitals
James J. Augustine, MD, FACEP
Medical Director, Washington Township (Ohio) Fire Department
Associate Medical Director, North Naples (Fla.) Fire Department
Director of Clinical Operations, EMP Management
Clinical Associate Professor, Department of
Emergency Medicine, Wright State University
steve berry, NRemt-p
Paramedic EMS Cartoonist, Woodland Park, Colo.
Bryan E. Bledsoe, DO, FACEP, FAAEM
Professor of Emergency Medicine, Director, EMS Fellowship
University of Nevada School of Medicine
Medical Director, MedicWest Ambulance
Criss Brainard, EMT-P
Deputy Chief of Operations, San Diego Fire-Rescue
Chad Brocato, DHS, REMT-P
Assistant Chief of Operations, Deerfield Beach Fire-Rescue
Adjunct Professor of Anatomy Physiology, Kaplan University
J. Robert (Rob) Brown Jr., EFO
Fire Chief, Stafford County, Va., Fire and Rescue Department
Executive Board, EMS Section,
International Association of Fire Chiefs
Jeffrey M. Goodloe, MD, FACEP, NREMT-P
Professor EMS Section Chief
Emergency Medicine, University of Oklahoma School of
Community Medicine
Medical Director, EMS System for Metropolitan
Oklahoma City Tulsa
David E. Persse, MD, FACEP
Physician Director, City of Houston Emergency Medical Services
Public Health Authority, City of Houston Department.
of Health Human Services
Associate Professor, Emergency Medicine,
University of Texas Health Science Center—Houston
Keith Griffiths
President, RedFlash Group
Founding Editor, JEMS
John J. Peruggia Jr., BSHuS, EFO, EMT-P
Assistant Chief, Logistics, FDNY Operations
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Department
Clinical Instructor, Ohio State University
W. Ann Maggiore, JD, NREMT-P
Associate Attorney, Butt, Thornton Baehr PC
Clinical Instructor, University of New Mexico,
School of Medicine
Connie J. Mattera, MS, RN, EMT-P
EMS Administrative Director EMS System Coordinator,
Northwest (Ill.) Community Hospital
Robin B. Mcfee, DO, MPH, FACPM, FAACT
Medical Director, Threat Science
Toxicologist Professional Education Coordinator,
Long Island Regional Poison Information Center
carol a. cunningham, md, FACEP, FAAEM
State Medical Director
Ohio Department of Public Safety, Division of EMS
Mark Meredith, MD
Assistant Professor, Emergency Medicine and Pediatrics,
Vanderbilt Medical Center
Assistant EMS Medical Director for Pediatric Care,
Nashville Fire Department
Thom Dick, EMT-P
Quality Care Coordinator
Platte Valley Ambulance
Geoffrey T. Miller, EMT-P
Director of Simulation Eastern Virginia Medical School,
Office of Professional Development
Charlie Eisele, BS, NREMT-P
Flight Paramedic, State Trooper, EMS Instructor
Brent Myers, MD, MPH, FACEP
Medical Director, Wake County EMS System
Emergency Physician, Wake Emergency Physicians PA
Medical Director, WakeMed Health Hospitals
Emergency Services Institute
Bruce Evans, MPA, EMT-P
Deputy Chief, Upper Pine River Bayfield Fire Protection,
Colorado District
Jay Fitch, PhD
President Founding Partner, Fitch Associates
Ray Fowler, MD, FACEP
Associate Professor, University of Texas Southwestern SOM
Chief of EMS, University of Texas Southwestern Medical Center
Chief of Medical Operations,
Dallas Metropolitan Area BioTel (EMS) System
Adam D. Fox, DPM, DO
Assistant Professor of Surgery,
Division of Trauma Surgery Critical Care,
University of Medicine Dentistry of New Jersey
Former Advanced EMT-3 (AEMT-3)
Gregory R. Frailey, DO, FACOEP, EMT-P
Medical Director, Prehospital Services, Susquehanna Health
Tactical Physician, Williamsport Bureau of
Police Special Response Team
10
JEMS
SEPTEMBER 2012
Mary M. Newman
President, Sudden Cardiac Arrest Foundation
Joseph P. Ornato, MD, FACP, FACC, FACEP
Professor Chairman, Department of Emergency Medicine, Virginia
Commonwealth University Medical Center
Operational Medical Director,
Richmond Ambulance Authority
Jerry Overton, MPA
Chair, International Academies of Emergency Dispatch
David Page, MS, NREMT-P
Paramedic Instructor, Inver Hills (Minn.) Community College
Paramedic, Allina Medical Transportation
Member of the Board of Advisors,
Prehospital Care Research Forum
Paul E. Pepe, MD, MPH, MACP, FACEP, FCCM
Professor, Surgery, University of Texas
Southwestern Medical Center
Head, Emergency Services, Parkland Health
Hospital System
Head, EMS Medical Direction Team,
Dallas Area Biotel (EMS) System
Edward M. Racht, MD
Chief Medical Officer, American Medical Response
Jeffrey P. Salomone, MD, FACS, NREMT-P
Associate Professor of Surgery,
Emory University School of Medicine
Deputy Chief of Surgery, Grady Memorial Hospital
Assistant Medical Director, Grady EMS
Kathleen S. Schrank, MD
Professor of Medicine and Chief,
Division of Emergency Medicine,
University of Miami School of Medicine
Medical Director, City of Miami Fire Rescue
Medical Director, Village of Key Biscayne Fire Rescue
John Sinclair, EMT-P
International Director, IAFC EMS Section
Fire Chief Emergency Manager,
Kittitas Valley Fire Rescue
Corey M. Slovis, MD, FACP, FACEP, FAAEM
Professor Chair, Emergency Medicine,
Vanderbilt University Medical Center
Professor, Medicine, Vanderbilt University Medical Center
Medical Director, Metro Nashville Fire Department
Medical Director, Nashville International Airport
Walt A. Stoy, PhD, EMT-P, CCEMTP
Professor Director, Emergency Medicine,
University of Pittsburgh
Director, Office of Education,
Center for Emergency Medicine
Richard Vance, EMT-P
Captain, Carlsbad Fire Department
Jonathan D. Washko, BS-EMSA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ Center for EMS
Co-Chairman, Professional Standards Committee,
American Ambulance Association
Ad-Hoc Finance Committee Member, NEMSAC
keith wesley, MD, facep
Medical Director, HealthEast Medical Transportation
Katherine H. West, BSN, MED, CIC
Infection Control Consultant,
Infection Control/Emerging Concepts Inc.
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg Wirth LLC.
Legal Commissioner Chair, Panel of Commissioners,
Commission on Accreditation of Ambulance Services (CAAS)
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg Wirth LLC
Wayne M. Zygowicz, BA, EFO, EMT-P
EMS Division Chief, Littleton Fire Rescue

11. Choose 17 at www.jems.com/rs

12. EMS IN ACTION
Scene of the month
12
JEMS
SEPTEMBER 2012
Photo Rick McClure

13. Precarious Pileup
E
MS providers from Los Angeles County Fire Department, American
Medical Response, Bowers Ambulance Service and MedResponse
Ambulance Inc. work together alongside personnel from the Los
Angeles County Sheriff’s Department and California Highway Patrol
to triage 17 people involved in a major vehicle pileup on the Antelope
Valley (14) Freeway. The freeway traverses a mountainous, remote area
in northeastern Los Angeles County. The crash happened on June 26
near the town of Agua Dulce. For more details on how providers managed, treated and transported patients in this complex mass casualty
event, see “MCI Magnifiers: Many factors can complicate an incident of
any size,” pp. 54–57, by A.J. Heightman, MPA, EMT-P.
www.jems.com
SEPTEMBER 2012
JEMS
13

15. Choose 18 at www.jems.com/rs

16. from the editor
putting issUes into perspective
by A.J. HEIGHTMAN, MPA, EMT-P
It’s All about the Pump
Maintaining the basics is key to effective cardiac resuscitation
16
JEMS
SEPTEMBER 2012
Photo A.J. Heightman
A
t a conference I participated in
recently, Jason McMullan, MD, associate medical director for the Cincinnati Fire Department, made a statement
during a lecture that I want to pass along
because it illustrates the critical importance
of consistent, uninterrupted compressions
and care delivery to cardiac arrest patients.
He pointed out that if his heart were
interrupted in its pumping functions for
even a few precious seconds, he would
experience an interruption in oxygenated
blood flow and pass out.
He also noted that the longer the heart
was allowed to be dormant, the longer the
risk was for bad things to occur and the
more difficult it would become to return
the heart to its essential pumping efficiency
and sustain life. So resuscitation is really
all about the pump: timing, efficiency
and consistency.
I think back to my early days as a paramedic and the infrequent cardiac arrest
“saves” I had. In almost all my successful
resuscitations, someone was performing
effective CPR early, a shockable rhythm was
present, and I was able to rapidly draw the
paddles from my defibrillator and shock the
rhythm while it was primed, well oxygenated
and “ripe.”
In the wild, wild West days, if a gunfighter
delayed in getting his gun into action, his
chances of winning the battle were less than
50%. The same is true in cardiac arrest resuscitation. You can chuckle about me using those
old-fashioned paddles to shock v fib, but I bet
I can still get my paddles on a patient’s chest
faster than you can dig out, unpackage and
deploy your pre-packaged defibrillator pads.
The point: Technology can sometimes present
delays in care delivery if not performed rapidly and in a consistent, systematic manner.
The September issue of JEMS focuses on
cardiac issues, from our regular content to
the special 32-page EMS State of the Science editorial supplement developed and presented
to you and attendees at the bi-annual Emer-
As with any task, a continuous supply of a fluid and the initial priming of the pump is key to success.
gency Cardiac Care Update (ECCU) Conference in Orlando, Fla.—where the latest
information on cardiac care and resuscitation
will be discussed.
In the supplement, developed in cooperation with the U.S. Metropolitan Municipalities EMS Medical Directors Consortium and
multiple sponsors, we feature a host of key
articles, backed up by 150 pieces of research,
that demonstrate why delivery of resuscitation processes in the field needs to be quickly
administered and, most importantly, consistently delivered.
In addition to the supplement articles, each
of the JEMS articles in this issue presents
significant messages that are important for
you to read, digest and discuss with your
medical director, management team, supervisors, training staff and field crews. Each also
emphasizes important processes or procedures that can increase your efficiency and
effectiveness in the field, particularly in the
resuscitation of cardiac arrest patients and
improvements in return of spontaneous circulation (ROSC).
In “Attacking Cardiac Arrest,” pp. 34–39,
we focus on a systematic approach to resuscitation in the Tulsa and Oklahoma EMS
systems. In “Check the Rhythm,” pp. 40–45,
we discuss the correct and effective use of
adenosine, the drug of choice for paroxysmal supraventricular tachycardia (PSVT) and
for differentiating PSVT with aberrancy from
v tach in patients with monomorphic wide
complex tachycardias.
Like many other potent medications
designed for a specific effect on the heart,
adenosine, if used inappropriately or for the
wrong arrhythmia, can prove fatal.
A thought-provoking question-andanswer session by EMS blogger and writer
Brandon Oto, “Survive and Thrive,” pp.
58–59, rounds out the issue by presenting
multiple important procedures that we currently deploy in the field, or may deploy in
the future.
You’ll read several common elements of
cardiac resuscitation in both September JEMS
and the editorial supplement. But the real
take-home message is that the keys to resuscitation are early initiation of each procedure,
limited interruption of compressions and a
pre-planned, systematic approach to everything you do on these critical cardiac resuscitation calls. And remember, success is all
about the effective use of the pump. JEMS

17. Choose 19 at www.jems.com/rs

18. LETTERS
in your words
I work in a dynamic system. Our response times would
be faster, no doubt about it, but only if you have the
correct number of units available to respond. Without a
high level of responders, response times that should take
less than six minutes end up taking 20 minutes.
Also consider the half-life of your employees. Sitting
for 12 hours a day, four days a week in a cramped ambulance isn’t healthy. I’ve seen EMS providers as young as
25 taking blood thinners. Obesity is becoming a real issue,
as well as the ability to pack healthy and efficient meals
for lunch and dinner, which doesn’t help the dynamic
systems cause.
In my opinion, dynamic systems increase response
times by one or two minutes at most. And that system
only works if the provider is staffed correctly. On the
other hand, stations increase the time an employee can
serve his or her community. The question is: Which is
more important?
Nathan Brooks
Via jems.com
I believe that the trend is to cross-train and diversify. I’m a strong supporter of combo units (a mini
pumper of sorts) staffed with two firefighters, a
police officer and a paramedic personnel. When
this has been tried, it has been very successful, but
only when the system is designed from scratch.
Politics and empires will control change in the traditional departments.
This will allow more units to be used and be capable
of multitasking. It will end aerial ladder trucks responding to sick patient calls. It will deliver 250 gallons of
water with a reel line that can handle most fires if
they’re attacked quickly enough. And it will reduce the
stagnant periods that so many paramedics normally
experience. This means more pay for more skills, more
units for quicker response times and more efficient use
of resources.
Tom Richards
Via Jems.com
18 JEMS
SEPTEMBER 2012
I was so excited to see the front cover of the July issue
of JEMS. I couldn’t wait to read the article. But I was
disappointed to see it was more of an opinion piece that
didn’t tell us anything new.
As far as response times go, they’re never fast
enough. From the information I have, the main response
time is initiating CPR within four minutes of arrest.
Nobody has enough money or the technology to
accomplish this through EMS alone. This is up to the
bystander who calls in. As far as dynamic vs. static
deployment goes, how many people reach the retirement age of 60 with 25–30 years running eight to 12 calls
a day in a 12-hour period?
If a patient can be transported to a hospital within
the same amount of time it takes to do the paperwork
required for a refusal, obtain the two required blood
pressures, call their doctor or go through an on-call nurse
to set up the appropriate treatment plan, the private
ambulance service will choose the transport. Even the
public EMS will choose this because it’s quicker to get
the unit out to handle the call volume of a dynamic
system. You start taking more than an hour on a call
and you don’t transport the patient, and you need more
ambulances on the street to make response times, which
costs more money. Will communities really invest in their
call-takers and call reporting systems?
The catch is that if you don’t dispatch an ambulance right away and the call goes from a low-level
to a high-level response, then you get dinged for not
making the high-level response time because of the
time it takes to go through the entire set of questions. If it takes four to six minutes to go through
the whole questionnaire, then the ambulance is
almost to the scene by the time the call-taker is
finished (at least in the cities). You might as well keep
sending ambulances.
Bob Farley, EMT-P
Author Jonathan D. Washko, BS-EMSA, NREMT-P, EMD,
responds: Sorry for your disappointment. Unfortunately,
I’m only given so many words and so much space to
express concepts and ideas that quite honestly could
fill volumes.
You’re correct in your observation related to the
initiation of CPR and the timeliness associated with
starting effective chest compressions and survival. You
are also correct that few can afford to provide a fourminute response time standard with first response or
transport assets.
You may note in my article I discussed the initiation
of CPR by a variety of methods, the first being dispatch
life-support (DLS). DLS is pre-arrival instructions given
by trained emergency medical dispatchers following
clinical algorithms that provide lay callers the instructions necessary to get care initiated before EMS arrives.
In many communities that embrace this type of system,
Hi Guys. No ambulance needed.
I’m a paramedic and have cleared
my C-spine already.
illustration steve berry
‘New’ Methods?
The article featured on the July JEMS cover,
“Rethinking Delivery Models: EMS Industry
May Shift Delivery Methods,” by Jonathan
D. Washko, BS-EMSA, NREMT-P, EMD, garnered a great deal of interest from readers.
What is ‘the new normal’ of EMS, and how do
you embrace it? Also, a JEMS Connect discussion thread about the use of lights and siren
at night generated a conversation among
Facebook fans regarding this hot topic. Do
they do more damage than help?

19. Watch Steve Berry and JEMS
Editor-in-Chief AJ Heightman tell
you why this book is a must-read!

20. LETTERS
continued from page 18
pre-arrival instructions save countless lives through the
immediate (within a minute or so of 9-1-1 activation) initiation of lifesaving treatments. My point is that response
times do count in survival and many EMS systems that
have improved response times (although they may not
have published their findings) have also seen correlated
improvements in cardiac arrest return of spontaneous
circulation (ROSC) rates.
The mechanism by which the response time
improves may vary, for example, the use of dispatch
life support or system status management or just adding
more resources into the EMS system or a combination
of these in order to yield improved clinical results. The
point is that systems attempting to achieve this with
traditional deployment methodologies are financially
unsustainable for a variety of reasons.
To your next concern regarding human sustainability,
I agree. Workloads must be balanced in order to provide
not just long-term financial stability but also the stability
of our teams. Unfortunately, dynamic deployment (like
any other tool) can be used for good or bad. It’s how
the tool was used that matters. I know many individuals
in balanced high-performance EMS systems that have
worked their entire careers in the field and love the
work they do.
To your third point, regarding whether private
entities will embrace the concepts associated with
healthcare reform, my answer is that they’ll have no
other choice. As I mentioned in the article, once the
economic conditions change and population-based payments replace fee-for-service payment methodologies,
a shift in how we have to deliver care will take place
driven by market force innovation and the dollars available to provide care. As this shift occurs, our mission in
EMS will also shift toward keeping patients out of the
emergency department and placing them in the proper
locus of care.
Next, you’re correct in your concerns related to
the legal risks associated with triage and care referral
systems versus treating and transporting everyone. It
is evident that the U.S. healthcare system practices risk
avoidance in pretty much everything it does; however, if
we’re to overcome these obstacles, we must shift from
risk avoidance to risk tolerance, and the government will
have to help us accomplish this through reform or some
other mechanism.
Finally, your point about performance-based contracting is spot on. Regulators will have to also evolve
and create penalty and reward systems designed around
new goals and objectives. We may also see a shift in the
regulators moving from government-based ones toward
payer-based or provider-based governance models as
their bottom lines.
Lastly, this little known excerpt from Jack L. Stout
addresses many of my critics and is one of the impetuses
that drives me to do what I do every day:
“As EMS providers, we invite the public to literally
trust us with their lives. We advise the public that,
during a medical emergency, they should rely upon our
organization, and not any other. We even suggest that it
is safer to count on us than the resources of one’s own
family and friends. We had better be right. Regardless
of actual performance, EMS organizations do not differ
significantly in their claimed goals and values. Public
and private, nearly all claim dedication to patient care.
Efficient or not, most claim an intent to give the community its money’s worth. And whether the money comes
from user fees or local tax sources, the claim is the same.
Our moral obligation to pursue clinical and response
time improvement is widely accepted. But our related
obligation to pursue economic efficiency is poorly
understood. Many believe these are separate issues.
They are not. Economic efficiency is nothing more than
the ability to convert dollars into service. If we could do
better with the dollars we have available, but we don’t,
the responsibility must be ours. In EMS, that respon-
sibility is enormous—it is impossible to waste dollars
without also wasting lives.”
Use of Lights Siren
Lights for safety on scene ... but if it’s a residence, we
will usually turn them off once we arrive and no sirens
at night in town .... we live in a small rural community
and traffic is generally not an issue.
Leslie Lloyd
Via Facebook
This issue again ... Sigh. Sadly, we as a profession of caring, are stuck utilizing all emergency signaling devices
to be recognized as an emergency operation. Litigation
against our fellow professionals has consistently found
us at fault when we try to be ‘reasonable’ to the public
and run silent to aid a neighbor. Running silent draws
the criticism that we don’t take the response seriously.
Using the signaling devices wakes everyone up and gets
us tagged as hooligans with no regard for the public. It
is with a wince that I flip the switches and roll using the
signaling devices as the lesser of the evils is not getting
you and your department stuck in a lengthy and costly
litigation should the untoward take place.
David M. Neptune
Via Facebook
If the nature of the call merits an emergency response
it gets one. An emergency response means lights AND
sirens, not lights OR sirens. The time of day has nothing
to do with it. JEMS
Bob Upson
Via Facebook
Do you have questions, comments or concerns
about recent JEMS or JEMS.com articles? We’d love
to hear from you. E-mail your letters to editor.jems@
elsevier.com or send to 525 B St. Suite 1800, San Diego,
CA 92101, Attn: Allison Moen.
interesting FACT ABOUT a photo that ran in our
August 2012 issue
Photographer Kathy Keatley Garvey took this rare photo that won an
international award and has drawn international acclaim on the Internet. It
was named one of the top images of 2012 on Huffington Post and also was
select as “Picture of the Day” on numerous websites. Garvey captured this
image of a bee stinging Cooperative Extension apiculturist Eric Mussen of the
University of California, Davis, Department of Entomology in the apiary of
the Harry H. Laidlaw Jr. Honey Bee Research Facility, UC Davis. What’s unusual
about this photo is that this sting was not a clean break; you can see the
abdominal tissue being pulled out as the bee tries to leave.
Kathy Keatley Garvey is a communications specialist with the UC Davis
Department of Entomology and a former newspaper editor but enjoys taking
macro photos of insects in her leisure time. She also writes a daily educational
Bug Squad blog on the UC Agriculture and Natural Resources website; the
blog, a volunteer blog, has garnered some 3 million hits in three years.
20
JEMS
SEPTEMBER 2012

21. Choose 20 at www.jems.com/rs

22. PRIORITYUSE
TRAFFIC
NEWS YOU CAN
Aurora Active shooter
News media prematurely critiques incident
AP Photo/Ed Andrieski
J
ust after midnight on July 21, moviegoers and responders in Aurora, Colo., were
subjected to real-life horror and chaos
when a heavily armed gunman dressed in full
body armor exited and returned via a rigged
door during a premiere showing of the latest
Batman movie, “The Dark Knight Rises” and
fired on the packed audience. The gunman
killed 12 people and wounded 58 others.
It was a horrific event, complicated by
many factors: the early morning time, a dark
environment both inside and outside the
theater, and the presence of a chemical agent
designed to debilitate the victims and make
easier, less resistive targets. Not to mention
the incident also involved the panicked and
chaotic exodus of hundreds of moviegoers—
many with serious injuries—who fled, in all
directions not only from the fully packed
room, but also into other nearby rooms, hallways and concession areas.
Many horribly injured victims who fled
from a multitude of exits sought help from
the first public safety personnel they could
find. In many cases, the first person of contact
was a police officer. Although EMS and fire
resources were on the scene and still responding, the multitude of factors presented above
didn’t allow for a standard mass casualty
incident (MCI) set up and action plan.
A gag order by the judge overseeing the
legal aspects of this case has limited the
release of information about the incident and
ability of responders to tell their side of the
story. So it’s frustrating to read newspaper
accounts and challenges about the way the
Aurora Fire Department and their contracted
ambulance provider, Rural/Metro Corporation, responded, treated and transported
patients. The local media has been critical of
the seemingly short supply of ambulances
during the first 30 minutes of the incident.
And much has also been written about the
police transporting victims rapidly from the
scene to definitive care.
Any seasoned responder who has arrived
on scene at an MCI knows that even under
Police officers were thrust into a patient transportation role in Aurora.
the best of conditions, a mass exodus of the out to be a key lifesaving effort—as it was
injured and uninjured from an incident can when President Ronald Reagan was shot in
be difficult to manage. Sorting out the injured Washington, D.C. and rapidly transported to
in a dark parking lot and at multiple exit a trauma center in his limousine.
JEMS will report on this major incident
points is a complex task. The rapid transportation of victims from that scene with criti- when appropriate clearances are received.
cal penetrating and exsanguinating gunshot Until then, don’t prejudge our colleagues in
wounds in police vehicles may in fact turn Aurora. —A.J. Heightman, MPA, EMT-P
Defending Their own
The media was critical in initial reports of a slow EMS response of resources to the Aurora shooting,
but JEMS Facebook fans quickly jumped to their defense:
Michael Torchia: We can train for these situations but no two situations are ever the same, and
we’re humans not robots. The press never says, “they did two things wrong but 100 things right.”
Suzi Pierce-Green: I saw where our agencies were on the news saying they practice and prepare
for such an event, and all I could think is NO MATTER how much you prepare it’s a charlie foxtrot and
everyone just does their best. My hat is off to them in the great job they did!
KimiAnn Corey: People need to understand we have a system/protocols we have to follow
for that stuff. There were on scene within minutes, but they had so many patients in the parking lot
bombarding [them] that they couldn’t just bypass.
Bobby Dorrell: You’re not helping anyone if you as a responder get hurt. In a situation like that,
scene safety is the top priority.
Join the conversation at www.facebook.com/jemsfans
Audio from Aurora shooting: www.jems.com/video/news/audio-colorado-theater-shooting
22
JEMS
SEPTEMBER 2012

23. Federal Law Addresses Critical Drug Issues
MS providers are patient
advocates and voices for
the sick, injured, and sometimes, even the deceased.
During such events as the
unfortunate mass shooting at the movie theater in
Aurora, Colo., providers are
often tasked with ensuring
family members and relief
agencies know about the
status of the victims. Thankfully, Health Insurance Portability and Accountability Act (HIPAA) makes the sharing of critical patient information a little easier
during an MCI.
Disaster Relief Entities: HIPAA allows EMS providers to share information about a patient’s location, general condition or death with an agency
that’s authorized to assist in disaster relief
Pro Bono is written by attorefforts. This information can be shared with
neys Doug Wolfberg, Ryan
the disaster relief agency for the purposes
Stark and Steve Wirth of
of notifying a family member, a personal repPage, Wolfberg Wirth LLC,
resentative of the patient or another person
a national EMS-industry law
responsible for the patient’s care. So EMS
firm. Visit the firm’s website
providers can release patient information
at www.pwwemslaw.com for
to such entities as the American Red Cross,
more EMS law information.
a state emergency management agency or
another similar type of entity to enable that organization to contact
someone who’s responsible for the patient’s care.
Family Members and Friends: HIPAA also permits EMS providers to disclose information about a patient’s location, general condition or death
to a patient’s family member, relative, close personal friend or any other
person who might be involved in the patient’s care. Bystanders, however, are a different story. Even if a bystander is truly concerned about
a patient’s welfare, or may have even assisted the patient before you
arrived on the scene, you may not share patient information with them,
unless the patient agrees.
There are two rules that you must follow when providing patient information to relief agencies or family and friends:
1. If the patient is competent and able to make healthcare decisions, you
should first obtain the individual’s agreement to share the information,
or at least give him/her an opportunity to object. The patient’s verbal
agreement is enough. You can also infer from the circumstances that
the patient doesn’t object to you sharing the information. For example, if you ask the patient if there’s anyone you can contact and they
say “my spouse,” you can infer that the patient is OK with giving information to the spouse.
2. If the patient is incapacitated, which is often the case in MCIs,
then providers can disclose patient information if they believe that
disclosure is in the best interests of the patient. HIPAA permits
providers to use their best judgment here in gauging how much
information they should share. Just remember to keep the patient’s
Robert Kneschke/Dreamstime.com
E
Choose 21 at www.jems.com/rs
www.jems.com
SEPTEMBER 2012
JEMS
23

24. continued from page 23
best interests in mind and to not disclose
more than the patient’s location, general
condition or death.
Finally, there’s always the concern about others
overhearing discussions between two crew members or radio transmissions. But these types of inevitable disclosures are called “incidental disclosures”
under HIPAA and generally don’t pose a HIPAA violation. In addition, if it’s necessary to ask a bystander,
police officer, news reporter or other non-medical
person to assist you in treating, moving or transporting a patient in a mass casualty situation, you
may do so.
HIPAA always permits you to share patient information for treatment-related purposes with any
party who’s also involved in the treatment of the
patient. And it isn’t a HIPAA violation to transport
multiple patients in an ambulance or other vehicle.
Sometimes, an emergency simply overwhelms the
available resources, and HIPAA recognizes that incidental disclosures will occur.
All of us at Page, Wolfberg Wirth would like
to express our deepest sympathy for the victims
and everyone affected by the tragedy in Aurora.
We also express utmost gratitude to all of the
responders who answered the call on that fateful
morning, and those across the U.S. who continue to
answer that call every day. We’re honored to represent an industry that’s solely committed to the
care of others in need.
The authors are all attorneys with Page, Wolfberg Wirth, a national EMS law firm. Visit the firm’s
website at www.pwwemslaw.com for more information on a variety of EMS law issues.
QUICK TAKE
As emergency medicine evolves, the National Institutes of Health (NIH) recently opened an Office of Emergency
Care Research (OECR) to bridge research from institute to institute and from academia to institute. At this
time it’s composed of an office of two to three people, a working group of 23 and a steering group of five.
Walter Koroshetz, MD, is its acting director.
“This was the recommendation of a steering committee’s strategic plan to create this office. We want
to be sensitive to all of our institutes,” he says.
After five years of discussion with the NIH and the emergency medicine community, the creation of the
office was announced late in July.
The NIH is composed of 27 institutes, such as nursing, neurology and child health. With the new office,
the many disciplines of research that fall under the huge tent of emergency medicine have the potential to
work together better and become greater than the sum of their parts.
“We all do emergency research. The OECR is a convergence point between those institutes,” Koroshetz says.
Although still in its infancy, Koroshetz is excited about the prospects and will recruit a permanent director. “The time is right. Research in an emergency setting is more feasible now working with a good set of
investigators. —Devin Greaney
For more of the latest EMS news, visit JEMS.com/news
Choose 22 at www.jems.com/rs
24
JEMS
SEPTEMBER 2012

25. Choose 23 at www.jems.com/rs

26. LEADERSHIP SECTOR
presented by the iafc ems section
by gary ludwig, ms, emt-p
First Day
Now what?
B
ob is a newly promoted EMS manager
who has been hired from another
state to lead an EMS agency. On his
first day, things didn’t go well. He came into
the office and greeted only his secretary and
next in command. People who wanted to
meet him never got the chance because the
second-in-command monopolized his time.
The second and subsequent days went the
same way. Bob never got out of the office.
Soon, word trickled to those working in the
field that the new boss was an unfriendly,
aloof jerk. As could be predicted, everything
went downhill from there.
EMTs, paramedics, and people who
worked in the EMS administrative offices
really didn’t like Bob. He could never
get everybody on board with the
changes he wanted to implement.
People within the EMS organization
became resistant to him, didn’t like
his approach and grumbled about
every policy he issued.
Within six months, Bob was looking for
a new job because he wasn’t happy either.
Within a year, the Board of Directors let
Bob go. What did Bob do wrong? He had
a wonderful track record in his other EMS
organization, and he had a fantastic resume.
What Bob failed to recognize is that if
you’re the new leader of an EMS organization, it isn’t business as usual on the first day
you walk through the door.
recognized by the boss on the first day. Make
sure you meet every employee, acknowledge
them and give them a personal greeting—
from the janitor all the way up to your secretary or the next in command.
When you first enter a new organization
as the new boss, you should remain positive.
If you’re critical of the organization’s current operation—especially if you’re coming
in from the outside—it might not go over
well. People will see it as an attack on their
organization. Even though you’re a part of
the organization, you haven’t been accepted
yet. Such statements as, “We did it this way
where I just came from” may polarize you
and your employees.
Next, I recommend not changing any-
A QI officer would show up at your station
and make you sign the form acknowledging
that you missed something. Quite frankly, it
really pissed people off when the situation
was their 12th trip of the day at 4 a.m. and
they failed to check a box on the patient care
report. It was one of the major things I heard,
and it really seemed to set them off. I failed
to see the significance of the form because it
seemed to make the QI process punitive with
having to sign the form acknowledging you
did something wrong.
So looking for the “low-hanging fruit”
and looking for the chance to set the right
positive attitude being the “new guy” coming in from the outside, I immediately got
rid of the QI form. The response was overwhelmingly positive and upbeat.
The crews were elated with my
decision. They felt I was a good
selection for the organization and
I was going to move the EMS part
of the fire department forward. It
helped me consolidate support for some
of the tough decisions I had to make down
the road with changes that were necessary,
while maintaining high morale.
Make sure you meet everyone,
acknowledge them give
them a personal greeting.
Your First Day
I’ve always seen this as a make-or-break
point. I’ve seen some good people get run
out the door because of the way they came in
the door. Everybody’s going to be watching
what a new manager does and says, as well as
observing how they react to different situations. If you’re a new EMS manager and have
come in from the outside, your employees
will really be watching you.
My first suggestion is to say “hello,”
and meet everyone. People want to feel
important, and they certainly want to be
26
JEMS
SEPTEMBER 2012
thing until you learn the works and the
dynamics that make it function. It’s especially important not to change anything that
has to do with the culture of the organization. If your first act is to change the patch or
the name of the organization, expect a tremendous amount of resistance and trouble.
People who are already within the organization have created their identity with the
organization. Although some may grumble, they still take pride in the organization
they’re associated with. Taking that away
from them can only bring you headaches.
My Experience
When I came to Memphis seven years ago,
I got around and talked to most of
the firefighter/paramedics about the
organization and how EMS operated
in the department. One of the biggest
complaints I heard was about a quality improvement (QI) form that was
issued to everyone from a QI officer if you
missed something on the patient care report.
Conclusion
Being new to an EMS organization is a challenge. If you’ve moved a great distance,
there’s added stress with moving and finding
housing. There’s no need to add to that stress
by taking the wrong approach with your
entry into the organization. Stay focused,
observe and start slow. If you’re successful
with your entrance, you will have an easier
time down the road making the changes you
think are necessary. JEMS
Gary Ludwig, MS, EMT-P, has 35 years of
EMS, fire and rescue experience. He currently
serves as a deputy fire chief for the Memphis
Fire Department. He’s also Chair of the EMS
Section for the International Association of
Fire Chiefs. He can be reached through his website at
GaryLudwig.com.

27. Choose 24 at www.jems.com/rs

28. TRICKSour patients ourselves
OF THE TRADE
caring for
by Thom Dick, EMT-P
Stealth Mode
Is all this noise really necessary?
28
JEMS
september 2012
Photo Chris Swabb
M
y state has a law that says if your
emergency warning lights are
on during a response, your siren
needs to be on as well. Always. Most laws
here are pretty sensible. But like so many
things that stipulate “always” or “never” in
this business, this one’s goofy.
There are times when the last thing you
want to do is advertise your arrival or your
intentions in advance. That’s true all the
time in some neighborhoods. And it’s fundamental on interstates, where you pretty
much have to expect other drivers to do
silly things.
Just for a moment, Life-Saver, put yourself in the mind of the motorist I’m about
to describe.
It’s close to dusk. You’re cruising home
from work at 65 miles per hour, nodding to
your favorite loud music. Suddenly and without warning, you’re overwhelmed by a pair
of siren speakers that somehow got within
20 feet of your rear bumper. (Yep, that’s way
too close.) In addition, your rearview mirror
reveals a big blue, elliptical Ford sign with a
few inches of a shiny grille around it, and its
silver details reflecting the rhythmic flashers
of—ohmigosh—an ambulance. (How’d that
get there?)
What would you do? Seriously, would
you have a seizure? Wet yourself? Pull over
quickly and switch places with your frontseat passenger? Slam on the brakes? Speed
up and pull to the right without so much as a
glance for traffic in the adjoining lane? Lower
your window and wave for them to pass?
Flip them off? Or turn up the music and
drown out that awful woop-woop noise?
Even a year of experience should tell you
that if those options were actually offered
on a driver’s license renewal test as multiplechoice answers, plenty of licensed drivers
out there would consider at least a few of
them as viable options.
See, I don’t think most drivers are accustomed to making emergency decisions. And
when they try, they sometimes make errors
Ambulances should go into stealth mode
during the night instead of flooding cities with
unnecessary noise.
in judgment. (At 65 miles per hour even the
smallest errors can have big consequences,
can’t they?)
I think of emergency warning equipment
as a tool. And I think its applications are
generally different on city streets than on
interstates. On city streets (at lower speeds),
a siren keeps pedestrians on the sidewalk
and helps an ambulance get people’s attention from behind so you can ask for the right
of way. (Remember it’s ask, not demand.) On
interstates, you use it instead to mitigate
traffic flow once you’ve gotten past other
motorists. But either way, you need the flexibility to choose which kinds of warning
equipment to use in any given situation. (That might include no warning
equipment at all, even during highpriority calls.)
On interstates, the California
Highway Patrol (CHP) routinely
employs the use of no forward-facing
lights and no sirens while they’re en route
to interstate calls. The CHP has known for
years that most drivers can’t hear a siren at
higher speeds until you’re right on top of
them. Most drivers also don’t monitor their
rearview mirrors, so they tend to not notice
those forward-facing lights anyway. Officers concentrate on sneaking through traffic
without startling or scaring anybody. They
try to use their rear-facing lights to advise
drivers in their wake that they’re responding to an incident. That helps them explain
their use of the shoulders, lane changes and
sometimes speed.
As emergency vehicle operators, it’s
incumbent on us to think for other drivers.
We should be doing no harm, not only medically but also in regard to our emergency
driving. And as you know, we can do a lot
of harm by causing just one other driver
to panic.
It’s time to abandon our outdated practice
of flooding our cities and interstates with
noise every time we respond to an emergency. It’s time for all emergency vehicle
operators to consider some sort of stealthmode option as a matter of routine, especially on busy interstates. I also advocate one
other thing, and I realize not everyone will
agree with it.
You can usually tell when your warning
equipment is confusing people. When that
happens, your safest option is to shut it
down and advise your communications center that you’re cutting your “code” response
due to traffic. That gives dispatchers the
option of selecting a more appropriate unit
for your call, or at least it tells them you’re
going to be delayed. Delay is an acceptable
option to hurting innocent people.
Especially our own. JEMS
Thom Dick has been involved in EMS for
41 years, 23 of them as a full-time EMT and
paramedic in San Diego County. He’s currently
the quality care coordinator for Platte Valley
Ambulance, a hospital-based 9-1-1 system in
Brighton, Colo. Contact him at boxcar414@comcast.net.

29. Choose 25 at www.jems.com/rs

30. CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
BY Travis Polk, MD, Carrie Sims, MD
Life Limb
Tourniquet saves man severely injured in vehicle crash
I
t’s easy for a current and former military
physician working in a busy urban trauma
center to look around and see the countless advances in trauma care that have been
translated from the military to civilian experience. This month’s case highlights just one
of the many lessons learned from caring for
injured service members.
When a 72-year-old male who was driving
unrestrained in his sedan along the highway
was suddenly struck from behind, he lost
control of his vehicle and it rolled. His left
arm, which was resting in the open window,
was crushed.
Philadelphia Fire Rescue medics arrived at
the scene and found the patient in a large pool
of blood with a severely deformed left arm
dangling by what seemed to be a thin connection of soft tissue. There was profound, pulsatile bleeding. Medics applied a tourniquet
to the arm above the injury and tightened it
until the bleeding stopped. They then immobilized the patient on a spine board, obtained
IV access and administered morphine for pain
control, splinted his arm with blankets as
best they could and transported him to the
trauma center at the Hospital of University
of Pennsylvania as a “trauma alert,” the highest level of activation. The patient remained
hemodynamically stable during the transport.
Hospital Course
On arrival, the trauma team quickly completed a primary survey, attached the patient
to monitors, exposed and rolled the patient,
and obtained additional IV access. Initial
vital signs were heart rate=126, blood pressure=162/100, respiratory rate=20, temperature of 96.9° F and pulse oximetry of
100%. His Glasgow Coma Scale score was 15.
Secondary survey was notable for some spinal tenderness, abrasions on the back and the
obvious near amputation/de-gloving deformity of the left forearm. The tourniquet was in
place above the elbow, and the bleeding was
30
JEMS
SEPTEMBER 2012
Photo Courtesy Travis Polk
Prehospital Course
This image shows the patient’s arm with a tourniquet shortly after arrival in the emergency department.
stopped. A focused assessment with sonography in trauma (FAST) ultrasound exam
showed no blood in the abdomen, and a chest
X-ray was unremarkable.
The tourniquet was carefully released to
better examine the arm. This resulted in severe
pain for the patient in the area above and
surrounding the wound. Pulsatile bleeding
appeared to emanate from the vicinity of the
radial artery. A limited neurologic exam of the
hand with the tourniquet released revealed no
evidence of motor or sensory function during
this brief interval. Because of the persistent
bleeding, the tourniquet was reapplied.
The patient remained in extreme pain
and became agitated. At this point, since a
neurologic exam had been performed and
the patient would be going to the operating
room (OR), the medical team proceeded with
elective endotracheal intubation to provide
adequate sedation and analgesia. Following
intubation, the patient was brought to the
computed tomography (CT) scanner for
imaging of his head, C-spine, chest, abdomen
and pelvis. No other injuries were identified.
The Operating Room
The patient was brought to the OR and
underwent repair of the radial artery, ligation of the ulnar artery, external fixation of
the radius and ulna, extensive irrigation and
debridement of devitalized tissue, and wound
coverage with cadaveric skin. He was extubated the following morning, and examination of his hand revealed mostly intact
sensation and slight movement in his thumb
and fingers.
Of note, the patient’s medical history was
significant for coronary artery disease and
deep vein thrombosis. On initial evaluation,
he reported taking aspirin, clopidogrel and
warfarin. He was treated with vitamin K via IV
and transfused with fresh frozen plasma and
platelets for presumed drug-induced coagulopathy. His initial hemoglobin was 10.3 gm/
dL with an international normalized ratio
of 1.1. Given his history of significant blood
loss and ongoing hemorrhage, he was transfused three units of packed blood cells in the
OR. His tetanus status was unknown, so he
received a tetanus vaccine. He was treated
with broad spectrum antibiotics for his open,
severely contaminated fracture.
At the time of this article, the patient
had left the intensive care unit, but he
remained in the hospital three weeks. On

31. the road to salvation of his limb, the patient
had five surgeries, including placement of
antibiotic impregnated beads and free-flap tissue transplantation.
Exsanguinating hemorrhage from isolated
extremity trauma in the civilian setting is
rare. Unfortunately, due to mixed messages
in much of the civilian medical literature and
first aid texts, many providers are hesitant to
place a tourniquet for fear of causing further
injury or committing the patient to an amputation. The military experience during the
past several years, however, has demonstrated
how this simple technology can be both lifeand limb- saving.
Historically, the mortality rate from
exsanguination from extremity trauma on
the battlefield has been approximately 9%.1
A retrospective study of special operations
personnel deaths in the global war on terror found that 13% of the potentially preventable deaths might have been prevented
with a tourniquet.2 Likewise, a large prospective study examining the use of prehospital
and emergency department tourniquet use
in a combat support hospital in Iraq found
that early use of tourniquets not only
provided hemorrhage control but also
improved mortality.
In a series of more than 400 applied tourniquets, no amputations were associated with
inappropriate tourniquet use, and few were
associated neurologic complications.3 For
these reasons, in 2005, the U.S. Army adopted
a new standard Tactical Combat Casualty Care
guideline that tourniquets should be first-line
treatment for any life-threatening extremity
trauma while under fire.
Although extremity trauma in the civilian
setting is rare, studies show that it’s deadly. A
similar retrospective study of exsanguinating
extremity trauma in the civilian population
identified 14 patient deaths during a period of
five and a half years at two Level 1 trauma centers in Houston. Of these 14 patients, 57% had
wounds that would have been amenable to
the placement of a tourniquet, and therefore
potentially could have been saved.4
Conclusion
Given this information, civilian EMS providers
should feel confident that placing a tourniquet
for severe extremity hemorrhage that isn’t
controlled by other means is safe, appropriate
Radiograph Courtesy Travis Polk
Discussion
This plain radiograph shows the severely comminuted fracture of the patient’s forearm.
and life-saving. Studies also show they should
be applied early and before the patient is
in shock.3
A variety of tourniquets are available for
EMS use. EMS units should work with their
medical directors to select and train with the
device that best suits their needs. As this case
illustrates, the use of a tourniquet was lifesaving for this patient and should always be
considered in cases of severe extremity
trauma. JEMS
Travis Polk, MD, is a trauma surgeon on active duty in the
U.S. Navy currently stationed at the Naval Medical Center in
Portsmouth, Va. He is board certified in general surgery and
board eligible in surgical critical care. At the time of this case,
he was an instructor in surgery and fellow in traumatology,
surgical critical care and emergency surgery at the University
of Pennsylvania in Philadelphia. He can be contacted at
travis.polk@med.navy.mil.
Carrie Sims, MD, is an assistant professor of surgery at
the University of Pennsylvania in Philadelphia and is a former U.S. Army Reserve Medical Corps Officer. She is board
certified in surgery and surgical critical care and practices as
a trauma surgeon and surgical intensivist. She can be contacted at Carrie.sims@uphs.upenn.edu.
Disclaimer: The views expressed in this presentation
are those of the author and do not necessarily reflect
the official policy or position of the Department of the
Navy, Department of Defense, or the U.S. government. Dr. Polk is a service member. This work was prepared as part of his official duties. Title 17, USC, §105
provides that “Copyright protection under this title is
not available for any work of the U.S. government.”
Title 17, USC, §101 defines a U.S. government work
as a work prepared by a military service member or
employee of the U.S. government as part of that person’s official duties.
References
1. Bellamy RF. The causes of death in conventional
land warfare: Implications for combat casualty care
research. Mil Med. 1984;149(2):55–62.
2. Holcomb JB, McMullin NR, Pearse L, et al. Causes of
death in U.S. Special Operations Forces in the global war
on terrorism: 2001–2004. Ann Surg. 2007;245(6):986–991.
3. Kragh JF, Walter TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb
trauma. Ann Surg. 2009;249(1):1–7.
4. Dorlac WC, Debakey ME, Holcomb JB, et al. Mortality
from isolated civilian penetrating extremity injury.
J Trauma. 2005;59(1):217–222.
When placing the tourniquet, providers should remember the following:
ighten until all bleeding stops. If the wound is still bleeding, you likely have a venous tourniquet, and it
T
may need to be tightened further or repositioned in order to occlude all arterial inflow.
lace as low on the extremity as possible.
P
ote the time that the tourniquet is applied. (Paperwork gets lost and people don’t always listen during the
N
report, so write it on the patient too!)
ourniquets are extremely painful; administer some pain medication.
T
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32. RESEARCH REVIEW ems
What current studies mean to
by David Page, MS, NREMT-P
Effective Care
Studies measure CO-detection device nausea treatment
I CO-Oximetry Effectiveness I
Weaver L, Churchill S, Deru K, et al. False positive rate of
carbon monoxide saturation by finger probe oximetry
of emergency department patients. Respir Care. 2012 Jul
10. [Epub ahead of print]
hould you trust your pulse CO-oximeter
(SpCO) monitor? During the past few
years, there have been conflicting messages
about the accuracy of these devices. This Salt
Lake City-based emergency department (ED)
group attempted to answer that question by
comparing Masimo RAD-57 SpCO monitor
readings from a finger probe/sensor, to the
carboxyhemoglobin (COHb) readings from a
simultaneous blood draw.
Three lab technicians collected SpCO and
COHb samples on 1,363 ED patients receiving blood draws from April to August 2008.
This was a non-randomized sample of convenience study conducted at a single hospital.
The authors report that 84% of the study’s
population was light-skinned and 45% were
male. Fifty-two of the people studied were
non-smokers. A variety of patient complaints
existed, but the SpCO monitor flagged 122
patients, meeting a false positive criteria. A
false positive was considered if the SpCO
showed a value greater than a 3% point difference than the actual COHb level.
Only four patients were actually diagnosed
with CO poisoning from the entire sample.
In these cases, the SpCO oximetry monitor
reading was 4–14% lower than COHb blood
levels, which led the authors to conclude
that the RAD-57 reports lower numbers than
COHb. So far so good, right?
Well, three other patients with COHb
greater than 10% received a 0% rating on the
SpCO monitor. If the SpCO value of 0% had
been used as a field triage tool, then these
patients may have not received necessary
evaluation and treatment at an ED.
So what should we conclude? First, the
good: Previous studies have followed some
flawed methodologies and didn’t adequately
describe the details of their methodologies.
32
JEMS
SEPTEMBER 2012
Photo david page
S
Researchers analyzed the false positive rate of carbon monoxide saturation on the RAD-57 monitor.
(See a review by Keith Wesley, MD, FACEP,
and Marshall Washick, NREMT-P at www.
jems.com/article/patient-care/rad-57-pulseoximeter-performa.)
The authors of this Salt Lake City hospital
study were careful to describe their methods
and avoid some of the previous pitfalls of
other researchers (e.g., timing of the blood
draw). The authors did not report whether the
sensors were shielded from excessive ambient
light, if patient motion was reduced, or if the
various sensor sizes were used, which are each
important considerations with the Masimo
CO-Oximeter. They did report that the device
performed within the margin of the manufacturer’s specifications.
And, from a purely statistical and research
perspective, the sample of patients with
detectible CO levels is simply too small to
make any meaningful conclusions.
The concern a study like this presents is
that, if we are to use this device for prehospital triage of potential CO exposures, then
it would be preferable that the device would
be sensitive enough to detect any potential
exposure, and perhaps err on the side of
over-triaging. Sending someone home based
on a RAD-57’s “0” or low reading if that
patient was actually sick, could be disastrous.
Regardless of whether this was an operator
or machine error, I worry about the patients
with 0% readings who had elevated blood
COHb readings.
I would feel pretty terrible sending someone home only to find out they had a
treatable condition that caused them harm
because of my lack of action. The controversy will continue, but this is an important
reason never to just base your field triage
decisions on any machines. Instead, providers should use these devices in conjunction
with other assessment processes and treatment tools, particularly when patients have
potentially been exposed to CO or have
CO symptoms.
I Nausea Cure? I
Fullerton L, Weiss S, Forman P, et al. Ondansetron oral
dissolving tablets are superior to normal saline alone
for prehospital nausea. Prehosp Emerg Care. 2012. [Epub
ahead of print.]
T
his prehospital cohort study compared
the use of normal saline bolus with an
odansetron orally dissolving tablet (ODT)
for the treatment of nausea. Researchers
enrolled 274 consecutive patients to receive
Bottom Line
What we know: The RAD-57 is being used by many systems across the country. The
machine has shown great promise and helped identify many CO exposures. Previous
research has raised concerns regarding its accuracy.
What these studies add: This study provides very weak evidence of a possible 9% false
positive rate and confusion about the trustworthiness of a low RAD-57 number based
on only five patients. More rigorous study is needed before any conclusions can be
made. Providers are encouraged to talk to their medical directors and be sure to receive
proper orientation and training before using any medical device.

33. normal ODT during a four-month period.
As you would have predicted, the ODT
group showed significantly decreased
nausea symptoms. No amount of normal
saline was able to show a significant effect.
No adverse events were reported, and the
two groups of patients were similar in ages
and severity of nausea. This study shows a
clear win for odansetron and for ALS care
making a difference.
Kudos to this group for doing prehospital research. Many of us have seen odansetron work its magic, but having some
science to back up its safe and efficacious
use makes for a more scientific and professional care standard. JEMS
I watch box I
Blanchette C, Dalal A, Mapel D, et al. Changes
in COPD demographics and costs over 20 years.
Journal Med Econ. 2012. [Epub ahead of print.]
This cross-sectional, population-based study
should pique the curiosity of community paramedic advocates. They report rapidly rising inhospital admission costs and more prevalence of
chronic obstructive pulmonary disorder (COPD)
in women. This survey of 416 respondents shows
a 37% increase in the cost of caring for COPD during the past 20 years. The authors conclude that
COPD has become a costly disease, which is now
more prevalent in women than men. The authors
recommend shifting costs to fund prevention and
conducting follow-up efforts to avoid readmission
of patients back into the hospital.
Perhaps the community paramedic model
will play a role in improving this part of the
healthcare system.
Choose 26 at www.jems.com/rs
I glossary I
Sample of convenience: A sample of
convenience is a grouping of research
subjects or values collected because
they were easily available. They aren’t
randomized or otherwise scientifically
selected, and generally they’re not representative of or able to be generalized to
an entire population.
Visit www.pcrfpodcast.org for audio
commentary.
David Page, MS, NREMT-P, is an educator
at Inver Hills Community College and a
paramedic at Allina EMS in Minneapolis/
St. Paul. He’s a member of the Board of
Advisors of the Prehospital Care Research
Forum. Send him feedback at dpage@ehs.net.
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34. Feedback-driven team performance impacts survival
By Jeffrey M. Goodloe, MD, NREMT-P, FACEP; T.J. Reginald, NREMT-P; David S. Howerton, NREMT-P;
Jim O. Winham, RN, BSN, NREMT-P; Tammy Appleby, NREMT-B
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35. Photo David Howerton
EMS providers go back to
the basics in training for
cardiac resuscitation.
A
s EMS professionals, we’re routinely challenged to successfully
resuscitate victims of sudden cardiac arrest. Fortunately, our
understanding of cardiac arrest pathophysiology continues to grow.
More fortunate still, our enthusiasm in translating that understanding to effective therapies has never been greater.
In the August 2012 issue of JEMS, we introduced a comprehensive restructuring of the EMS System for Metropolitan Oklahoma
City and Tulsa’s cardiac arrest program using a three-part approach:
chest compression fundamentals, resuscitation team dynamics and
accelerated feedback on resuscitation performance. We discussed
the benefit of going “back to the basics” of chest compression fundamentals training, increasing our rate to 120 chest compressions
per minute and using metronomes to attain and maintain that rate
throughout resuscitations. Now, we share how those fundamentals
were incorporated into a Resuscitation Team Playbook and how we
use directed feedback to further refine resuscitation performance.
For Step 1 and the introduction to this team’s approach to resuscitation, read “Oklahoma EMS System Strives for Higher Cardiac Arrest
Survival Rates” at www.jems.com /magazines/2012/august.
Step 2: Resuscitation Team Dynamics. Have you ever been a part of
an EMS call that was particularly “busy” in activity, yet when the
patient was transferred for further care, you started to think, “What
did we actually get done?” Us too. In fact, it happens to all of us in
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36. cardiac Arrest part II
continued from page 35
the inherently challenging practice of EMS medicine. We believe
what you do with those reflections can make all the difference
in the world for future patients. We therefore chose to turn our
reflections, and those of our colleagues, into a Resuscitation
Team Playbook that channels individual enthusiasms into a carefully orchestrated team performance, often described favorably
as “pit crew resuscitation.”
Figure 1 shows the positions used in our resuscitations, with
roles defined for teams of one to six professionals. In our EMS
system, we often start with resuscitation teams of two, three,
or four, with subsequently arriving responders building that
team to five or six actively contributing members. It’s rare in
our system that one EMT or paramedic would be tasked with
resuscitating a cardiac arrest patient alone, but it could happen
for a brief period if a patient were to collapse at a nearly empty
fire station or ambulance headquarters. We wanted to ensure
we had all the possibilities covered, including the single rescuer
scenario. Let’s review the key contributions provided by each
position, so that you’ll be certain to include the care most likely
to promote neurologically intact survival, regardless of resuscitation team size.
Position 1: Rapidly identifies arrest and initiates continuous
chest compressions.
lternates minutes of chest compressions with Position 2
A
over the course of the resuscitation.
When not compressing, assists with bag-valve-mask ventilations (squeezing the bag).
inimizes pauses in chest compressions for rhythm deterM
mination and/or defibrillation.
Position 2: Applies automated external defibrillator or monitor/
manual defibrillator.
irror image of Position 1.
M
Position 3: Provides airway management; avoids hyperventilation.
Position 4: Leads scene management.
Interface with family/bystanders for events preceding
arrest and medical history.
upervises positions 1–3 for continuous compressions,
S
timely defibrillation, and no hyperventilation.
Position 5: Provides ALS support.
hythm determination and manual defibrillation.
R
Vascular access.
Medication administration.
Position 6: Provides ALS support.
Patient management leader.
The full playbook can be accessed at
www.jems.com/patient-care
At first, it looks like a lot of instruction—because it is. However, these directives simply expand in detail on the key contributions at each position. You may think this degree of directive
is micromanaging hardworking EMS professionals who already
know the right things to do in time-sensitive situations. You’re
right; it actually is micromanaging, but let’s look at why cardiac
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SEPTEMBER 2012

37. arrest calls for no less.
Try this exercise, literally. Do 20 jumping jacks. What do
you feel? Unless you’re in particularly athletic shape, you likely
feel an increase in pulse and in respiratory rate and effort.
Why? You’re compensating for an increased activity demand.
The human body is amazing in its ability to compensate, even
to some degree when severely ill or injured. But spontaneous
circulation reflects an unforgiving light switch. When it’s “on,”
compensation is at work. When it’s “off,” as in cardiac arrest,
there’s complete loss of compensation … except for resuscitative efforts.
Thinking back to our understanding of cardiac arrest pathophysiology, we have to be precise in those efforts for our “compensation on loan” to work. The only way to make that happen
comes when we use a carefully crafted plan (the playbook) and
actively micromanage ourselves in each position (running the
play). So in sum, it’s not micromanaging by others, it’s self-micromanaging, and it’s for all the right reasons.
Figure 1: Resuscitation Positions
Scene
Management
P4
Airway
Management
P3
Chest
Compressions
Set Up
AED/Defibrillator
Chest Compressions
P1
Defibrillation
Vascular Access
Medication
Administration
P2
Patient
Management
P5
P6
We’ve definitely laid out a plan, but how do we know whether
it’s the right plan? One quick answer you’ll say is by looking at neurologically intact survival rates—before and after adoption of this
plan. In fact, that’s a great answer, but we think it comes up short
as the lone answer.
In athletics, if a team loses a game, does that mean they played
badly? Often, the answer is “not at all;” it may mean the team simply played a better team, or depending on how score is kept, the
team may have started with a handicap that’s insurmountable.
Ever start a resuscitation feeling that you were working with such
a handicap? That’s where Step 3 comes into use in our cardiac
arrest program.
Step 3: Feedback on Resuscitation Team Performance. Every highperformance professional values feedback designed to “build up”
future abilities. Our feedback program channels that philosophy
using proprietary software that captures data from the monitor/
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38. cardiac Arrest part II
continued from page 37
defibrillator throughout the resuscitation. Many EMS systems are
using this type of capability, but the real value lies in merging data
with a set of skilled clinical eyes, annotating the basic feedback
forms. Credit goes to the Redmond, Wash., Medic One program
for helping us see the full potential already in our grasp.
Only through annotating a case do specific gaps in compresEMS providers in Oklahoma
City and Tulsa maintain a
rate of 120 compressions,
using metronomes in
training.
Photo David Howerton
Choose 30 at www.jems.com/rs
sions, changes in ventilation rates and timings of defibrillation
really become clear. No “real world” resuscitation will ever be
textbook perfect. Thus, only through analysis by an experienced
clinician does variability reliably fall into the “makes sense”
or “opportunity to reflect” categories. Without annotation, a
“report card” gets generated without showing a valid grade …
arguably pointless, right?
Our goal is to have an annotated resuscitation team performance feedback report available to the resuscitation team on its
next shift after working a cardiac arrest. The report is sent with
explanation through annotated comments and without discouraging remarks, even in areas for improvement. Those areas are
self-evident, and we believe the best correction can come through
team reflection.
So how are we doing in achieving our own goal? Currenrtly,
just about 5% of the time. But here’s a key point, and one we’ve
had to learn with hard experience: If you wait until everything
is perfect to start improving, you never start improving. Like
38
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39. most EMS systems, we’re understaffed in comparison with our
goals. However, we’re fortunate in being able to hire a new data
specialist position that’s dedicated full-time in our Office of the
Medical Director. This position will dramatically improve our
feedback abilities, both in volume and timeliness.
Even with feedback 5% of the time, the results are encouraging. We’re routinely seeing chest compression fractions (CCF)
(i.e., time in which chest compressions are actively occurring)
above 90%. In fact, many resuscitations are being performed
with CCFs above 95%. (To be clear, these cases reflect random
analysis, not just review of clear survivors.) These numbers
reflect CCF increases 5–15% above our historical baselines. Not
surprisingly, return of spontaneous circulation (ROSC) rates
have increased since we started resuscitation team dynamics in
February. Although we anticipate cardiac arrest survival rates
in 2012 to be rewarding, it’s still early, and we don’t want to
report on incomplete data.
Conclusion (For Now)
Our EMS system, just like yours, is committed to attacking cardiac arrest and doing everything we can to help the suddenly dead
become alive again. Focusing our energies (with encouragement
from friends throughout EMS) on chest compression fundamentals, resuscitation team dynamics and better timely feedback on
resuscitation team performance—all in support of patients and
the EMS professionals caring for them—makes a lasting influence
on cardiac arrest. JEMS
Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is professor and chief of the EMS section
of the Department of Emergency Medicine at The University of Oklahoma School
of Community Medicine in Tulsa. He serves as medical director for the Medical
Control Board in the EMS System for Metropolitan Oklahoma City and Tulsa,
working with a multitude of agencies, including the Emergency Medical Services
Authority (EMSA), the Oklahoma City Fire Department and the Tulsa Fire Department. He started in EMS in 1988 as an EMT-B and has never quit learning. Contact
him at jeffrey-goodloe@ouhsc.edu
T.J. Reginald, NREMT-P, is director of research and clinical standards development for the Office of the Medical Director in Oklahoma City and Tulsa. He’s a
driving force behind the success and continuing advancement of cardiac arrest
resuscitation in the major metropolitan areas of Oklahoma. His EMS career spans
three decades and includes a multitude of clinical and administrative leadership
roles. Contact him at reginald@emsa.net.
David S. Howerton, NREMT-P, is director of Clinical Affairs - Western Division for
the Office of the Medical Director in Oklahoma City. He’s the medical oversight liaison officer for all metropolitan Oklahoma City agencies working with the Medical
Control Board. His EMS career spans nearly three decades and includes a multitude
of clinical and administrative leadership roles. Contact him at howertond@emsa.net.
Jim O. Winham, RN, BSN, NREMT-P, is the immediate past director of Clinical
Affairs - Eastern Division for the Office of the Medical Director in Tulsa. He’s enjoying
a new career move as the general manager for Paramedics Plus - Oklahoma. His EMS
career spans more than three decades and includes a multitude of operational, clinical and administrative leadership roles. Contact him at winhamj@emsa.net.
Tammy Appleby, NREMT-B, is executive assistant to the medical director for the
Office of the Medical Director in Oklahoma City and Tulsa. Retired from the U.S.
Air Force, she has an accomplished career in medical operation administration and
leadership. Contact her at applebyt@emsa.net.
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40. Photo Courtesy Portland Fire Department
Once adenosine is administered,
its effectiveness lasts between
five and 10 seconds.
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41. Expert safe use of adenosine depends
on patient’s cardiac status
By Corey Slovis, MD, FACEP; Jared McKinney,
MD; Jeremy Brywczynski, MD, FAAEM
denosine is the drug of choice for paroxysmal supraventricular tachycardia (PSVT) and is once again
Advanced Cardiac Life Support-approved for differentiating PSVT with aberrancy from ventricular tachycardia (v tach) in patients with monomorphic wide complex tachycardias.1 Adenosine is a
potent and safe antiarrhythmic when used appropriately. However, its use in the wrong patient or
rhythm can prove fatal. This article focuses on how to expertly use adenosine and to know when
this “safe” antiarrhythmic can be dangerous and contraindicated.
Pharmacology Mechanisms of Action
Adenosine’s mechanism of action can be thought of as a “temporary
paralyzing” of supraventricular tissue. Pharmacologically, adenosine
hyperpolarizes the cell by stimulating an inward potassium current
and temporarily inhibiting calcium migration.2 In doing so, the pacemaker activity of the sinoatrial (SA) node, spontaneous atrial activity
and conduction through the atrioventricular (AV) node are dramatically slowed or temporarily stopped.
Adenosine has no effects on accessory pathways, such as those
seen in the Wolf-Parkinson White Syndrome (WPW). Mild side
effects of adenosine are common. They include a transient sinus
pause that usually lasts less than five seconds, chest pressure or tightness, dyspnea, facial flushing and the feeling of impending doom (see
Table 1, below).2–4
Rare, benign side effects reported include anxiety and dizziness.
In one large prehospital trial, 11% of patients had a minor transient
complaint, with chest pain being the most common complaint seen
in 4% of patients.4 Chest tightness was induced by adenosine administration in 83% of patients in one large in-emergency department
(ED) study.5
to cause prolonged sinus pauses, syncope, seizures and even asystole, although this rare side effect has been described almost solely in
older patients with preexisting conduction disease and/or second- or
third-degree heart block.7–9 Adenosine is the drug of choice for PSVT
in pregnant patients.1
The biggest dangers with adenosine are seen in two groups of
patients: 1) those with atrial fibrillation or atrial flutter, and 2) those in
sinus tachycardia and not PSVT.
Figure 1a, 1b 1c: Regular Wide-Complex Tachycardia
Figure 1b
Side Effects
Side effects from adenosine administration that are serious are
extremely rare when used in healthy patients with PSVT (see Table 1,
below). Adenosine may cause mild bronchospasm, which is almost
always short lived. However, adenosine can also cause severe bronchospasm and should
Table 1: Toxicology of Adenosine
be given carefully to
Minor
Major
those with a history
of asthma or chronic
Chest tightness
Angina
obstructive
pulmoShortness of breath
Ventricular tachycardia
nary disease (COPD).6
Warmth
Bronchospasm
It shouldn’t be given to
patients who are already
Diaphoresis
Respiratory arrest
wheezing.
Adenosine
Impending doom
Cardiac arrest
has also been reported
Figure 1c
To verify true regularity, make marks on a piece of paper that match the
peaks of the QRS then moving the QRS-marked paper a few beats over to
compare it to three to four new beats on the rhythm strip. If they line up,
the rhythm is regular; if they don’t, the rhythm is irregular, and adenosine
shouldn’t be used.
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42. Check the Rhythm
continued from page 41
Numerous studies in the literature report
serious rhythm degeneration and even death
when adenosine has been inadvertently
given to patients with either atrial fibrillation
or atrial flutter. Adenosine can convert relatively stable atrial flutter with 2:1 conduction
and a heart rate of 150 to 1:1 conduction with
a heart rate of 300 and cause rapid clinical
decompensation.10
Adenosine slows or blocks antegrade
(atrial to ventricular) conduction through
the AV node but doesn’t affect accessory or
bypass tracts like those seen in WPW syndrome. Because of this, adenosine can be
dangerous when given to patients with atrial
fibrillation, especially if they have a bypass
track. Numerous reports show patients
degenerating into rapid atrial fibrillation
with rates at 250 or greater and becoming
hemodynamically unstable.10–13
Thus, an absolute contraindication to
adenosine exists in patients who have either
atrial flutter or an irregular rhythm in atrial
fibrillation. Because rapid atrial fibrillation
may seem regular on ECG monitor, paramedics are urged to run a rhythm strip and
verify true regularity.
We find this easiest by making marks on
a piece of paper that match the peaks of the
QRS then moving the QRS-marked paper a
few beats over to compare it to three to four
new beats on the rhythm strip. If they line
up, then the rhythm is regular; if they don’t,
then the rhythm is irregular (and likely atrial
fibrillation), and adenosine shouldn’t be used
(see Figures 1a, 1b, 1c, p. 41).
The other absolute contraindication to
adenosine is in sinus tachycardia. Dehydrated patients, especially the elderly with
fever, failure to thrive and/or an infection
may appear to be in PSVT when in fact they’re
barely compensated with a sinus tachycardia with a rate that may be greater than 150.
These patients are at high risk for morbidity
and mortality if adenosine is administered,
Table 2: When PSVT is not likely PSVT
Presentation
Reason It Is Not PSVT
Heart rate of 150 or less
At 150 atrial flutter 1:1; 150 or less usually is sinus tach
Irregular rhythm
Atrial fibrillation or multifocal atrial tachycardia
Transiently slows to vagal stimulation
Diagnostic of sinus tachycardia
History of atrial fibrillation, atrial flutter or multifocal atrial tachycardia (MAT)
Marked increased likelihood of previous arrhythmia and not PSVT
History of COPD or CHF
Atrial fibrillation or MAT much more likely
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SEPTEMBER 2012
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43. and they have a prolonged sinus pause (see
Table 2, below).
In cases for which there’s any chance
that sinus tachycardia is the etiology of the
patient’s elevated heart rate, a rapid fluid
bolus of 250 cc should be administered. Any
slowing by just a few beats per minute (rather
than a dramatic conversion to a normal sinus
rhythm) confirms the diagnosis of sinus
tachycardia due to volume depletion.
This is also true in heat stroke victims
with PSVT at rates approaching 180 beats
per minute. EMS providers should rapidly hydrate and cool these patients before
administering adenosine. If the patient’s
pulse begins to fall with therapy, the diagnosis of sinus tachycardia due to heat illness and
dehydration is confirmed, and adenosine is
contraindicated. Table 2 lists the rhythms,
rates and patient types in which the diagnosis of PSVT should be considered unlikely.
Administration Dosage
Once adenosine is administered, its effectiveness lasts only between five and 10 seconds because it’s rapidly metabolized by
cellular uptake. Because of the ability of
blood vessel endothelium to metabolize
adenosine, it’s imperative for EMS providers
to give adenosine by rapid bolus followed by
Figure 2: Prolonged Pause Status Post Adenosine
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a 10–20 cc rapid flush.2,3
Larger, more proximal IV lines are preferred because small-bore IVs don’t routinely allow fast flow or rapid transit to the
heart. The dosage of adenosine should be
reduced to 3 mgs if injected into a central
line, and it shouldn’t be used in heart transplant patients.1,14
The standard initial recommended dosage of adenosine is 6 mg, followed by a rapid
saline flush. If this dose isn’t effective, EMS
providers should double the dose to 12 mg,
repeat the bolus and rapidly flush the line.1–
15
These recommendations come from the
original article that compared adenosine

44. Check the Rhythm
continued from page 43
Table 3: Dosages Protocol for Adenosine Administration
Adenosine Dosing
6–12 mg IV push in large-bore IV
Immediately flush with 10–20 cc normal saline solution
12 mgs IV push if not effective in 60 seconds
If protocol began with 6 mg IV, consider second dose of 12 mgs IV; push and re-flush line.
Contact medical control in the event of refractory cases
with verapamil in PSVT and used a variety of adenosine doses. In this article, the
investigators found that 6 mg of adenosine
converted 62.3% of patients and that 12 mg
converted 91.4% of patients without increase
in toxicity.15,16
Because there doesn’t appear to be any
increased toxicity in a 12 mg initial dose
and it’s more effective, others have recommended starting at 12 mg.4,17 Some have recommended doses as high as 18 mg, which
can convert 95% of PSVT patients vs. 65%
with 6 mg and 90% with 12 mg.18
Thus, paramedics and their medical
directors should have pre-established protocols beginning with 6–12 mg. These protocol should conclude that a second 12 mg
dose should be attempted if 12 mg is ineffective,. This is because reports show a second repeat dose of 12 mg may convert up to
10–31% of patients.4,5
Treating Wide Complex
Tachycardia
Adenosine was initially considered useful
in helping distinguish wide complex tachycardias due to aberrantly conducted PSVT
vs. true v tach. However, based on cases
of patients deteriorating, many cautioned
against trying this drug in any patient with
wide complex tachycardia.14,16
We now know that adenosine is safe
and can help distinguish supraventricular
arrhythmias from those originating in the
ventricle for monomorphic wide complex
tachycardias that are regular in rate (and
by definition, have the same QRS size and
shape).1
In the largest recent study of adenosine
in wide complex tachycardias, 197 patients
were studied.16 Of these, 116 had SVT and
81 had v tach. Ninety percent of the SVTs
responded to escalating doses of adenosine
(i.e., administering 6 mg, then 12 mg, then
repeating 12 mg if no response, and even
administering 18 mgs to one patient). Only
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SEPTEMBER 2012
one patient with proven v tach responded
to adenosine, and a second patient may have
transiently slowed.
The authors concluded that adenosine was safe as long as patients had regular monomorphic wide complexes and that
adenosine was useful in helping distinguish
between PSVT and v tach. In fact, they noted
a 36-fold increase in the likelihood of a
adenosine are usually mild and transient,
lasting just a few seconds. They include
chest tightness, shortness of breath and a
short sinus pause. Although more serious
side effects can occur, such as hypotension,
bradycardias and seizures, these side effects
are rare in healthy patients with no underlying heart disease.
Adenosine is contraindicated in patients
who are likely to be harmed by its inappropriate use. Patients with irregular heart rates,
especially atrial fibrillation, patients with
PSVT mimics such as atrial flutter with 2:1
conduction or sinus tachycardia in a dehydrated or stressed patient should never
receive adenosine.
Adenosine should never be used in wide
irregular tachycardias. Providers who are
going to use adenosine must be experts in
An absolute contraindication
to adenosine is in patients who
have either atrial flutter or an
irregular rhythm as is seen in
atrial fibrillation.
supraventricular origin if the wide complex
tachycardia converted to sinus with adenosine and a nine-fold increased likelihood of v
tach if it didn’t respond to escalating doses
of adenosine.
Another thing is absolutely clear: Never
give adenosine to a wide irregular tachycardia or a polymorphic (multiple different QRS
configurations) tachycardia, such as Torsades de Pointes. It’s in these patients that adenosine might be lethal.1,16
Read about a real case of a patient
who presented with Torsades
de Pointes at www.jems.com/
torsades-de-pointes.
Summary, Conclusion
Recommendations
Adenosine is a safe and effective agent in
PSVT. It’s currently the EMS drug of choice
for regular tachycardias about 150–160
beats per minute, believed to be PSVT—
whether wide or narrow. The side effects of
cardiac rhythm interpretation. They also
must carefully review a rhythm strip prior to
drug administration.
Our recommended starting dosage is
12 mgs via IV push followed by a 10–20 cc
rapid flush of saline. If the first 12 mg dose
isn’t effective after one minute, we recommend repeating 12 mgs a second time. EMS
services and their medical directors should
decide whether 6 or 12 mgs should be initially used because there’s no national consensus on which is optimal. JEMS
Corey Slovis, MD, FACEP, is professor and chair of emergency medicine at Vanderbilt and serves as the medical
director for Nashville (Tenn.) Fire Department and Nashville International Airport. Slovis is also a member of the
JEMS Editorial Board.
Jared McKinney, MD, is director of event medicine for
Vanderbilt Medical Center, an assistant professor of emergency medicine at Vanderbilt University Medical Center in
Nashville and is an assistant medical director for the Nashville Fire Department.
Jeremy Brywczynski, MD, FAAEM, is medical director of Vanderbilt’s aeromedical LifeFlight Program and an
assistant professor of emergency medicine at Vanderbilt

45. University Medical Center in Nashville and is an assistant medical director the Nashville Fire Department.
References
1. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult advanced cardiovascular
life support: 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl
3): S729–S767.
2. Sampson K Kass R. Anti-Arrhytmic Drugs: Introduction. 12th. ed. Goodman
Gilman’s the Pharmacological Basis of Therapeutics 2011. McGraw-Hill: New
York.
3. Kowey P Yan G. Antiarrhythmic Drugs. 13th. ed. Hurst’s the Heart 2011.
McGraw-Hill: New York.
4. Gausche M, Persse DE, Sugarman T, et al., Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med.
1994;24(2):183–189.
5. Riccardi A, Arboscello E, Ghinatti M, et al. Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006). Am J Emerg Med.
2008;26(8):879–882.
6. Burkhart KK. Respiratory failure following adenosine administration. Am J Emerg
Med. 1993;11(3):249–250.
7. Christopher M, Key CB, Persse DE. Refractory asystole and death following the
prehospital administration of adenosine. Prehosp Emerg Care. 2000;4(2):196–198.
8. Reed R, Falk JL O’Brien J. Untoward reaction to adenosine therapy for supraventricular tachycardia. Am J Emerg Med. 1991;9(6):566–570.
9. Webster DP Daar AA. Prolonged bradyasystole and seizures following IV adenosine for supraventricular tachycardia. Am J Emerg Med. 1993;11(2):192–4.
10. Mallet ML. Proarrhythmic effects of adenosine: A review of the literature.
Emerg Med J. 2004;21(4): 408–410.
11. Exner DV, Muzyka T, Gillis AM. Proarrhythmia in patients with the Wolff-Parkinson-White syndrome after standard doses of intravenous adenosine. Ann Int
Med. 1995;122(5):351–352.
12. Haynes BE. Two deaths after prehospital use of adenosine. J Emerg Med.
2001;21(2):151–154.
13. Shah CP, Gupta AK, Thakur RK, et al. Adenosine-induced ventricular fibrillation.
Indian Heart Journal, 2001;53(2):208–210.
14. Delacretaz E. Clinical practice. Supraventricular tachycardia. New Eng J Med.
2006;354(10):1039–1051.
15. DiMarco JP, Miles W, Akhtar M, et al. Adenosine for paroxysmal supraventricular
tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group. Ann
Int Med. 1990;113(2):104–110.
16. Marill KA, Wolfram S, Desouza IS, et al., Adenosine for wide-complex tachycardia: Efficacy and safety. Crit Care Med. 2009;37(9):2512–2518.
17. Slovis CM, Kundencheck PJ, Wayne MA, et al., Prehospital management of
acute tachyarrhythmias. Prehosp Emerg Care. 2003;7(1):2–12.
18. Weismuller P, Kattenbeck K, Heinroth KM, et al. [Terminating supraventricular
tachycardia with adenosine--comparing the effectiveness of 12 mg and 18 mg].
Dtsch Med Wochenschr. 2000;125(33):961–969.
Read a clinical education article about heart
rhythms at www.jems.com/article/monitorsrecorders-vital-signs/rhythm-clues
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