TEXAS — At a preconference session for the National Association of EMS Physicians Annual Meeting, Dr. Dan Spaite, a professor of emergency medicine at the University of Arizona, gave an impassioned presentation about airway management in the prehospital setting. Specifically, he argued that the focus on the airway over proper breathing management is deadly to patients, and that essentially everyone in the chain of care is guilty of this biased focus.
Spaite’s lecture was part of a larger, morning-long session titled, “All Things Airway-Airway Management in the Fresh Cadaver,” which introduced participants to various airway management devices in a realistic setting. It mixed new technology with tried-and-true techniques in a way that allowed attendees to gain a more comprehensive understanding of the options on the market.
Memorable quotes on appropriate airway management
Here are some memorable quotes on appropriate airway management from Spaite’s presentation:
“Breathing is an afterthought, this is an airway course, not a ventilation course, because otherwise, no one would come.”
“We kept this patient alive for the last 20 minutes, don’t you kill them in the next 10 minutes” (regarding hyperventilation on arrival to the emergency department).
“Ventilators were a major downgrade from iron lungs.”
“Hyperventilation is really bad for TBI.”
“Proper ventilation is remarkably gentle.”
“You need to let them be apneic if they’re not hypoxic.”
Key takeaways on appropriate airway management
Spaite left attendees with the following takeaways and bad players in appropriate airway management.
Bad player No. 1: Positive pressure ventilation
Sick patients are at a higher risk of the homeostasis that remains in their system being upended when the negative pressure dynamics of ventilation are altered. By pushing air into the lungs rather allowing it to be sucked in, the body sees an increase in intrathoracic pressure along with a decrease in venous return to the heart, mean arterial pressure, and coronary and cerebral blood flow.
Bad player No. 2: Hyperventilation
When patients are ventilated too quickly, this can increase the negative effects of positive pressure ventilation. Additionally, this speeds the rate at which CO2 is removed from the body, increasing the risk of hypocarbia and the downstream consequence of cerebral vasoconstriction.
EMS research has done little to alleviate this issue as most publications on prehospital airway management focus on the processes leading up to the successful placement of the airway device with almost no focus on how the patient is ventilated for the remaining duration of their care. This lack of delineation between the two processes means that much of what we think we know about airway management in the prehospital setting is heavily confounded.
Bad player No. 3: Over-ventilation
Spaite defined over-ventilation as high tidal volumes and/or high airway pressures, and argued that unless processes are put in place to prevent this, manual ventilations in any setting are likely too high in pressure or too high in volume.
Spaite mentioned a number of solutions to this dilemma, including:
Using a device that provides some degree of a timing function
Adding additional personnel to exclusively monitor ventilation, EtCO2 and oxygenation
Using the two-finger technique to bag
Buying a smaller bag such that providers can only push a limited volume of air into the lungs on any one breath
The intubation/hyperventilation paradox
All of these issues combine into what Spaite referred to as the “intubation/hyperventilation paradox.” This paradox acknowledges that while intubation has the potential to help protect the airway and adequately oxygenate and ventilate the patient, it also puts them at an increased risk of increased intrathoracic pressure, hyperventilation and over-ventilation.
Additional airway management resources
Learn more about airway management with these resources from EMS1:
EMTs and paramedics administer numerous drugs, like epinephrine for anaphylaxis, albuterol for asthma, and nitroglycerine for chest pain, to treat life-threatening medical conditions and relieve patient pain. The administration of those drugs is governed by scope of practice rules or statutes and medical director-approved protocols.
The decisions of which drug formulations or brands to purchase, where to purchase drugs from and what volume of drugs to purchase are likely collaborative decisions made between the EMS agency operation’s director and medical director. Making those decisions requires the input of field providers and the analysis of patient care data. Here are the important questions to answer when purchasing EMS drugs.
Which drugs can a medical first responder, EMT or paramedic administer?
The drugs administered by medical first responders, EMTs and paramedics are determined by the providers’ state scope of practice. A paramedic in Wisconsin might have a larger formulary than a paramedic in Texas. An EMT in Pennsylvania may have two choices to treat hypoglycemia – oral dextrose or Glucagon – compared to an EMT in a neighboring state who may only have a single choice.
A state EMS authority or regional EMS authority likely maintains a drug formulary, which is the list of approved drugs for EMS providers in the authority’s jurisdiction. Depending on the state or region, the drugs on the list are reviewed and updated regularly
Who selects the drugs an EMS provider can administer?
An EMS agency’s medical director is responsible for authorizing drug administration through protocols, and authorizing certified and trained providers to practice under the medical director’s license. Administration of a specific drug is matched to a patient care protocol. A specific protocol is applied based on the patient assessment, which identifies:
For example, nitroglycerin is indicated for a patient with chest pain, a systolic blood pressure great then 90 mm Hg, and no recent use of a phosphodiesterase inhibitors, like Viagra. If a contraindication exists, such as a systolic blood pressure of 76 mm Hg, nitroglycerin is contraindicated and not administered.
Drug information, either in line with specific protocols or as an appendix, is available for each drug providers are authorized to administer. The common medication information is:
Repeat dose, if applicable
Who collaborates with the medical director to select a drug for the EMS formulary?
A team approach is used to evaluate the drugs already on the formulary, as well as selecting drugs to add to or remove from the formulary. Use a multidisciplinary team, including these representatives, to make formulary changes:
The multidisciplinary team, through a structured research and discussion process, could:
Identify the preferred benzodiazepine for a patient having a seizure
Update an ingested poison protocol to remove activated charcoal
Evaluate the delivery of bag-valve mask ventilations while naloxone is prepared for administration
Create a plan for when the agency would allow administration of expired medications
What are triggers to adjust the EMS drug list?
An EMS agency’s drug list, usually as part of an annual or every-other-year protocol review, can be adjusted for several reasons. The top reason to adjust a drug list is the availability of new evidence about a drug’s efficacy published in a peer-reviewed medical journal. Evidence-based medicine can also inform decisions to remove a drug from a formulary or narrow its indications for use.
Research: For example, in the last decade, the efficacy of tranexamic acid has been researched in the combat casualty care provided to soldiers with severe hemorrhage in Iraq and Afghanistan. The research on TXA has led to increased interest in administering the drug as part of civilian trauma care.
Ketamine is another drug that has seen an expanded list of indications in the last decade. Some paramedics now have protocols to administer ketamine for pain management, sedation for behavioral emergency or as an amnesiac for airway procedures.
There have also been significant changes to the medication types, doses and frequency of additional doses included in the advanced cardiac life support algorithms. A long-time paramedic has seen antiarrhythmic choices expand and contract in the last 20 years.
Price and availability changes: A drug’s price and availability can also play role in its purchase and use. Drugs, like nearly any other product, obey the laws of supply and demand. If supply is limited through changes in manufacturing, quality problems or even natural disaster, not only is the drug’s price likely to go up, but EMS services and their medical directors are likely to go searching for new vendors of the same drug, alternative concentrations of the drug, alternative administration routes for the drug, or entirely new medications to administer instead of the drug which is in short supply.
A nationwide shortage of EpiPens, used to treat anaphylaxis, led many EMS agencies to search for alternatives to the expensive auto-injector. Many operations directors and medical directors developed injection protocols and trained personnel in how to draw 1:1,000 epinephrine from an ampoule and administer 0.3 mg with a syringe. Several pharmaceutical vendors responded to the EpiPen shortage and newly revised protocols for anaphylaxis treatment by selling epinephrine injection kits.
Increased use: Narcotics overdoses have dramatically increased as the opioid epidemic has worsened in the last 10 years. As the epidemic rages, EMS agencies, as well as police and fire departments, have determined that naloxone can be administered by basic life support providers through intramuscular injection or intranasal spray. Pharmaceutical companies have responded with new devices and kits to meet the increased demand for easy-to-administer naloxone.
Mitigate drug diversion risk: EMS agencies are at risk of staff who divert or steal drugs, especially narcotics, for personal use or illicit sale. A drug formulary might be adjusted to mitigate risks of drugs being diverted from the EMS agency. Some of those actions might include purchasing:
A smaller volume of the drug
A lower concentration of the drug
Medications with less diversion risk
Drugs with increased tamper-resistant packaging
Risk mitigation needs to be balanced with the ongoing need to treat a patient’s acute pain from traumatic injury. Purchasing actions are one-leg in a three-legged stool, which also includes monitoring and secure storage to mitigate the risk of diversion.
How is an EMS drug inventory managed?
EMS agency drug purchasing is complicated by factors that are unique to the prehospital care environment. Unlike an emergency department or intensive care unit, an EMS agency needs to:
Store drugs in multiple places – stations, ambulances, quick response vehicles, fire apparatus and first-in bags.
Frequently move drugs from the ambulance to the patient’s side and back to the vehicle.
Protect drugs from severe fluctuations in ambient temperature.
Make drugs available to providers who may not actually administer the drug during their shift.
Monitor a drug’s expiration date through regular rig or vehicle checks.
A drug with a short shelf-life, infrequent indications for use, high price and narrow temperature range for safe storage isn’t likely to be adopted by EMS. The ideal EMS drug is:
Easy to store
Impervious to extreme temperatures
Cheap to purchase
Convenient to re-order
Read more about EMS inventory management.
What’s the role of quality improvement in EMS drug purchasing?
An EMS agency’s quality improvement program needs to include data collection and analysis of drug administration. Use data from electronic patient care reports to inform ongoing protocol updates and topics to cover in continuing education programs. These are a few of the data points that might be relevant to drug administration and purchasing:
Frequency of drug administration
Adherence to protocol for drug administration
Difficulties encountered administering a drug
Adverse patient reactions to the drug
Education needed to safely prepare and administer a drug
Make sure to include the volume and cost of drugs that expire before administration in the quality improvement program. Unused inventory can represent a major expense for an EMS agency. Use inventory control and purchasing methods to limit drug supply to meet regulatory requirements and the likely amount to be administered in upcoming shifts, weeks or months.
Drug usage statistics from a quality improvement program can be compared to purchase records to monitor for irregularities, increasing administration or declining use. Drug use stats may signal:
Change in a drug’s shelf life
Excess waste in the field
Diversion or theft
Worsening influenza or opioid epidemic
How are EMS drugs procured?
Select an EMS drug vendor that is best suited to the agency’s patient volume, provider scope of practice and the emergencies most frequently encountered. An EMS agency serving a winter vacation destination in the mountains is likely to regularly administer pain medications for musculoskeletal injuries. An EMS agency serving an industrial community with lots of older citizens is more likely to frequently treat the chronic diseases of aging like diabetes, heart failure and COPD.
Drugs are purchased by EMS agencies in several ways:
Single distributor: Individual agency purchasing from an EMS distributor
Group purchasing: Multiple agencies participating in a regional or group purchasing contract from a single vendor
Membership pricing: A cooperative, representing dozens or hundreds of agencies, negotiating pricing for drugs on behalf of its members
Some agencies enter into agreements to resupply drugs through the hospital systems patients are transported to. The EMS agency leverages the volume pricing the hospital obtains and shifts the burden of inventory management and purchasing to the hospital pharmacy.
What is the medical director required to sign?
The EMS agency medical director needs to sign a physician authorization to purchase. Many vendors will make an electronic version of this form available for ease of use. Purchasing controlled substances also requires completion of Drug Enforcement Administration paperwork, specifically DEA form 222.
The Protecting Patient Access to Emergency Medications Act of 2017 amended the Controlled Substances Act of 1970 to include DEA registration for EMS agencies, approved uses of standing orders, and requirements for the maintenance and administration of controlled substances used by EMS agencies. Every EMS medical director and operations director needs to understand and comply with PPEMA requirements for EMS use of controlled substances. Changes were made in these areas:
DEA registration for EMS agencies
Use of standing orders for controlled substances administration
Storage of controlled substances in the registered location, unregistered locations and EMS vehicles
Restocking EMS vehicles at hospitals with controlled substances
Maintenance of controlled substances records to meet the requirements of the Controlled Substances Act
EMS agency liability for proper use, maintenance, reporting and security of controlled substances rather than the EMS medical director
How can an EMS agency prepare for a drug shortage?
Make sure to understand the purchasing options available to your agency before you face a drug shortage, demand surge or vendor change. Here are five important questions to answer before a drug shortage:
What is your vendor’s policy for communicating to customers about drug shortages?
How will your vendor work on your behalf to find drugs during a shortage?
How will neighboring agencies assist one another if a drug becomes scarce?
Will your state make emergency modifications to the amount of a drug that EMS is required to stock if there is a shortage?
Will your agency medical director or state medical director authorize EMS providers to administer expired medications?
Why are relationships important to EMS drug buying?
Relationships always matter. Regardless of the product, nature of the purchasing relationship or the supply and demand, these things always influence a purchasing decision:
Price of the product or service
Ease of purchasing
Compare prices during annual budgeting or monthly repurchasing. Know the options available to your agency and make sure to check with references about customer service, delivery expediency and billing practices before picking a new drug supplier. Jumping from vendor to vendor might save an EMS agency a few dollars in the short run, but building a long-term relationship with a vendor you know and trust is critical to ensuring product is available and your agency is insulated, to some degree, against wild price and inventory fluctuations.
What are your suggestions for purchasing EMS drugs? What types of purchasing arrangements have worked well for your service? Leave a comment below or email firstname.lastname@example.org with your feedback.
CES 2019 is well underway in Las Vegas and, by the looks of the thousands of new products being debuted, the future is now.
We’ve combed through the robots and gadgets and found the best tools that will make life as a first responder easier … when they become available to the public, that is. Whether you’re looking to navigate difficult terrain or get a good night’s sleep, here are 10 items that stand out so far.
1. Hyundai walking car concept
“Elevate” is the first Ultimate Mobility Vehicle (UMV) with moveable legs designed to help first responders navigate through the treacherous terrain that often comes with natural disasters. With the use of robotics and electric car technology, Elevate can climb over a 5-foot wall and step over a 5-foot gap, and can still maintain highway speeds.
“Imagine a car stranded in a snow ditch just 10 feet off the highway being able to walk or climb over the treacherous terrain, back to the road potentially saving its injured passengers – this is the future of vehicular mobility,” Hyundai Design Manager David Byron said.
2. Chronolife vest
France-based health tech company Chronolife has created a vest they say has the capability to predict the likelihood of a heart attack. The company says the cotton and Lycra vest measures six physiological stats to help monitor those diagnosed with chronic or congestive heart failure. It doesn’t require internet connection or any charging, and it’s machine washable.
The company hopes to receive FDA approval this summer.
3. Hupnos anti-snoring sleep mask
A top cause of sleep deprivation at the station is your snoring colleagues, right? This mask is hoping to alleviate the noise by pairing with an app that monitors your sleep and determines when snoring begins. Once detected, the mask vibrates to nudge you to move to another sleeping position and increases the Expiratory Positive Airway Pressure to stop the snoring if the movement doesn’t do the trick.
You can currently purchase one on Indiegogo.
Speaking of a good night’s rest, the Urgonight wants to train your brain to sleep better. The headband connects to an app on your phone and helps your brain develop wave patterns that will result in healthier sleep. Developers said it takes about three months to achieve sustainable results through three 20 minute sessions per week.
The device is set to be available for purchase later this year.
5. Withings Move ECG
It looks like a regular analog watch, but this fitness watch can measure electrocardiograms for a third of the price of an Apple Watch S4. Achieve a reading by touching both sides of the watch’s bezel for 30 seconds while wearing it. The data will be sent to an app on your phone.
The watch is currently under review for FDA clearance and is expected to hit the market later this year.
6. AerBetic wearable blood sugar level tracker
The AerBetic was designed to change the lives of diabetics by using exhaled breath instead of pricking a finger. The device, which looks like a silver watch without a face, is targeted on “gasses indicative of high and low blood sugar events,” according to AerBetic Co-founder and COO Eric Housh.
“We’re able to pair that with a companion app. The app can alert not only the patient … but can also alert a network of caregivers,” Housh added.
The device will be available to purchase in late 2019.
7. Omron HeartGuide blood pressure monitor
With nearly 50 percent of firefighter line of duty deaths caused by cardiovascular issues, it’s important to stay on top of your heart health. This wearable device, which is currently available for purchase, comes equipped with an inflatable blood pressure cuff hidden behind the wrist band that works just like the one your doctor uses. The data is stored in the device’s memory and can also be reviewed on an app.
8. Harley Davidson LiveWire electric motorcycle
Police officers patrolling on motorcycles might be excited to hear that Harley Davidson’s long-awaited green machine is now available for pre-order. The electric motorcycle can reach 60 mph in under 3.5 seconds and comes equipped with an H-D Connect system that uses LTE to allow you to check on your bike remotely, find out if someone is trying to steal your ride and receive service reminders.
9. R-Pur Nano mask
Officers on both motorcycles and bicycles are exposed to air pollution, and this mask is hoping to reduce that risk by filtering toxic particles such as bacteria, viruses and dangerous particles found in diesel exhaust.
It can be worn under any type of helmet and comes with a valve to let hot air out when you’re exerting yourself. The mask even lights up to alert you of the surrounding air quality, glowing green for good air and red for bad.
The mask will be available for purchase in the U.S. later this year.
10. LG CLOi SuitBot
The first “human-centric” wearable could potentially reduce the physical strain first responders often face in the field by supporting and enhancing the user’s legs. The design aims to allow the robot to move in a more natural way. On a less natural note, the SuitBot can connect with other service robots to form a smart working network, and can even use biometric and environmental data to learn and suggest optimal movements for maximum efficiency.
Would you use any of these high-tech gadgets? Be sure to weigh in below.
SCOTTSDALE, Ariz. —Axon (Nasdaq: AAXN), the global leader in connected public safety technologies, today announced that Cypress Creek Emergency Medical Services (EMS) will deploy 93 Axon Flex 2 cameras across the agency’s paramedics and paramedic supervisors to improve clinical practice and enhance evidence-based research. The cameras are backed by the digital data management solution, Axon Evidence (Evidence.com) on the Unlimited Plan. This order was received and shipped in the fourth quarter of 2018.
“We conducted a trial with Axon cameras in 2014 and it proved to be an invaluable teaching tool that improved our clinical practice and sped up advanced certifications,” says Cypress Creek EMS Executive Director Bradley England. “The use of this technology contributed to saving at least two lives because our paramedics were able to show ER doctors exactly what they saw in the field.”
“Our goal is to provide the best technology solutions for all members of the public safety industry so they can get to the truth faster,” says Axon CEO and founder, Rick Smith. “By offering all first responders the opportunity to capture and share critical video and other data on one network, they are able to seamlessly work together to improve health and safety in their communities.”
Axon Flex 2 cameras enable point-of-view video with unlimited HD and a 120-degree field of view. To learn more visit: www.axon.com/flex-2.
About Axon Axon is a network of devices, apps and people that helps public safety personnel become smarter and safer. With a mission of protecting life, our technologies give customers the confidence, focus and time they need to keep their communities safe. Our products impact every aspect of a public safety officer’s day-to-day experience.
We work hard for those who put themselves in harm’s way for all of us. To date, there are more than 325,200 software seats booked on the Axon network around the world and more than 210,000 lives and countless dollars have been saved with the Axon network of devices, apps and people.
Learn more at www.axon.com or by calling (800) 978-2737.
The Butler County man’s interest in space made him a perfect fit to offer his time at the Heinz History Center’s Destination Moon exhibit. But little did he know, the 65-year-old man was about to get help from Jeannette EMS and the center’s head of security when his first day as a volunteer took a sharp turn.
“I am so blessed by this fortuitous sequence of events at that place at that time,” Mahoney said.
Jeannette EMS paramedic Del Black and Gregg Shearer, an emergency medical technician, were at the Strip District museum Oct. 3 to teach a CPR class for employees when a security guard got a call: someone collapsed downstairs.
The pair and head of security Cody Stanoszek rushed to the exhibit and found Mahoney lying on the floor. The Connoquenessing man had just arrived minutes earlier.
“He was in full cardiac arrest,” said Black, of North Huntingdon.
They took over breathing and chest compressions while Stanoszek prepared an on-site AED, or automated external defibrillator. After the third shock, Mahoney came to, said Stanoszek, also of North Huntingdon.
“We brought him back to life before the paramedics showed up,” said Shearer, of Irwin.
Pittsburgh EMS whisked Mahoney away to UPMC Presbyterian, where doctors placed stents in his heart within 45 minutes. Mahoney doesn’t remember anything after arriving at the exhibit and chatting with a security guard until he awoke the next day. Blame it on the “widowmaker,” a heart attack caused by an arterial blockage that can be fatal in minutes.
Stanoszek was relieved to get a phone call later that Mahoney was going to be OK.
“He just had all of the help he needed within a very short period of time,” Heinz History Center volunteer coordinator Ellen DeNinno said.
Mahoney made an emotional return to the center in November and met with some of those who had helped to save his life, including Stanoszek. Mahoney thinks about the circumstances that got him to the Heinz History Center that day — he believes it’s all more than just coincidence.
“If I hadn’t had an interest in the space program, I wouldn’t be down there — I’m dead,” he said.
Stanoszek said the center is seeking a grant to get more AEDs, something Shearer recommends any public building have. All three men were awarded heroism certificates and pins from The Sudden Cardiac Arrest Association through UPMC.
Mahoney, who retired in March as a power transmission engineer, has recovered and said he feels better than he has in years. He returned for his second first day as a volunteer last month and is on the schedule throughout January.
“I do believe God orchestrated the whole thing,” Mahoney said. “I really think that he has some plans for me. For whatever reason, he didn’t want to take me that day.”
Renatta Signorini is a Tribune-Review staff writer. You can contact Renatta at 724-837-5374, email@example.com or via Twitter @byrenatta.
HOUSTON — An EMS agency will be the first in the U.S. to equip its paramedics with full body cameras.
Cypress Creek EMS will deploy 93 Axon Flex 2 cameras across its agency after going through a trial period with the devices and proving their worth.
“We conducted a trial with Axon cameras in 2014 and it proved to be an invaluable teaching tool that improved our clinical practice and sped up advanced certifications,” CCEMS Executive Director Bradley England said. “The use of this technology contributed to saving at least two lives because our paramedics were able to show ER doctors exactly what they saw in the field.”
The cameras will “enable point-of-view video with unlimited HD and a 120-degree field of view,” according to a press release.
Axon CEO and Founder Rick Smith said the company aims to “provide the best technology solutions” to first responders.
“By offering all first responders the opportunity to capture and share critical video and other data on one network, they are able to seamlessly work together to improve health and safety in their communities,” he said.